Provider Demographics
NPI:1831144872
Name:MISRA, SOUNAK N (MD)
Entity Type:Individual
Prefix:
First Name:SOUNAK
Middle Name:N
Last Name:MISRA
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 1:2530 SE 26TH AVE APT 407
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1484
Mailing Address - Country:US
Mailing Address - Phone:913-636-9616
Mailing Address - Fax:971-270-2806
Practice Address - Street 1:700 N HAYDEN ISLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-8130
Practice Address - Country:US
Practice Address - Phone:971-533-5840
Practice Address - Fax:971-270-2806
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26161207R00000X, 207RG0300X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271033Medicaid
ORP00294103OtherRR MEDICARE
ORP00294103OtherRR MEDICARE