Provider Demographics
NPI:1780648048
Name:MISRA, VIRENDRA K (MD)
Entity Type:Individual
Prefix:
First Name:VIRENDRA
Middle Name:K
Last Name:MISRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:2603 W RAWSON AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8422
Practice Address - Country:US
Practice Address - Phone:414-431-6760
Practice Address - Fax:414-431-6761
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI385802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000001093OtherMEDICARE PTAN
WI32336900Medicaid
WI32336900Medicaid