Provider Demographics
NPI:1790791887
Name:MISHRA, JAGDISH P (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:P
Last Name:MISHRA
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 1:215 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1649
Mailing Address - Country:US
Mailing Address - Phone:585-343-3205
Mailing Address - Fax:585-343-5038
Practice Address - Street 1:215 SUMMIT STREET
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1649
Practice Address - Country:US
Practice Address - Phone:585-343-3205
Practice Address - Fax:585-343-5038
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215983207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1296Medicare PIN
RB6308Medicare UPIN
NYIA0010Medicare UPIN