Provider Demographics
NPI:1184161630
Name:MISHRA, PRAVEEN
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
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 1:1580 SAWGRASS CORP PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:954-501-5796
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRASS CORP PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323
Practice Address - Country:US
Practice Address - Phone:954-501-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL070021283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist