Provider Demographics
NPI:1780667725
Name:MISHARK, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:MISHARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5777 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32703208M00000X
AZ25611208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001227900Medicaid
AZ392407Medicaid
AZ110158815OtherRR MEDICARE
AZ86080015085259A386OtherTRIWEST
AZ110158815OtherRR MEDICARE
FL001227900Medicaid
FLCB849ZMedicare PIN