Provider Demographics
NPI:1245300664
Name:SANJEEB K. MISHRA M.D., P.A. CHARTERED
Entity type:Organization
Organization Name:SANJEEB K. MISHRA M.D., P.A. CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJEEB
Authorized Official - Middle Name:K
Authorized Official - Last Name:MISHRA
Authorized Official - Suffix:
Authorized Official - Credentials:D23031
Authorized Official - Phone:301-645-8322
Mailing Address - Street 1:3581 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3270
Mailing Address - Country:US
Mailing Address - Phone:301-645-8322
Mailing Address - Fax:
Practice Address - Street 1:3581 OLD WASHINGTON RD
Practice Address - Street 2:SUITE D
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3270
Practice Address - Country:US
Practice Address - Phone:301-645-8322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD3783735207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD69870100Medicaid
MDCJ5151OtherRAILROAD MEDICARE
DCG00649Medicare PIN
MDG80957Medicare UPIN
MD69870100Medicaid
MDCJ5151OtherRAILROAD MEDICARE