Provider Demographics
NPI:1245681659
Name:MISHRA, PRABODH
Entity type:Individual
Prefix:
First Name:PRABODH
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 1:300 20TH AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5180
Mailing Address - Country:US
Mailing Address - Phone:931-648-0064
Mailing Address - Fax:
Practice Address - Street 1:647 DULOP SUITE 200
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-648-0064
Practice Address - Fax:931-553-4215
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL39709207R00000X
TN65950207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine