Provider Demographics
NPI:1790932630
Name:MISHRA, MARK VIKAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VIKAS
Last Name:MISHRA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:500 UPPER CHESAPEAKE DRIVE RADIATION ONCOLOGY
Mailing Address - Street 2:UPPER CHESAPEAKE MEDICAL CENTER
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4324
Mailing Address - Country:US
Mailing Address - Phone:443-843-5609
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DRIVE RADIATION ONCOLOGY
Practice Address - Street 2:UPPER CHESAPEAKE MEDICAL CENTER
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-843-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2013-09-20
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Provider Licenses
StateLicense IDTaxonomies
IL125-055026207R00000X
PAMT1947312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD75962OtherLICENSE NUMBER
PAMT 194731OtherSTATE MEDICAL LICENSE