Provider Demographics
NPI:1265580724
Name:MISHRA, VINOD (MD)
Entity type:Individual
Prefix:
First Name:VINOD
Middle Name:
Last Name:MISHRA
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 1:6958 BROCKTON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3802
Mailing Address - Country:US
Mailing Address - Phone:951-784-6790
Mailing Address - Fax:951-784-9919
Practice Address - Street 1:6958 BROCKTON AVE STE 201
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3802
Practice Address - Country:US
Practice Address - Phone:951-784-6790
Practice Address - Fax:951-784-9919
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38396207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383960Medicaid
CA00A383960Medicare ID - Type Unspecified
CA00A383960Medicaid