Provider Demographics
NPI:1962488825
Name:MISHRA, SHYAM N
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:N
Last Name:MISHRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 IRVING RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-4614
Mailing Address - Country:US
Mailing Address - Phone:586-268-1990
Mailing Address - Fax:586-268-1991
Practice Address - Street 1:8202 IRVING RD
Practice Address - Street 2:SUITE 200
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4614
Practice Address - Country:US
Practice Address - Phone:586-268-1990
Practice Address - Fax:586-268-1991
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0508435Medicare ID - Type Unspecified
MIA76574Medicare UPIN