Provider Demographics
NPI:1669962148
Name:MISHRA, POOJA ELIZABETH (MD)
Entity type:Individual
Prefix:MS
First Name:POOJA
Middle Name:ELIZABETH
Last Name:MISHRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE STE 3003
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2528
Practice Address - Country:US
Practice Address - Phone:616-267-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2024-08-26
Deactivation Date:2018-12-19
Deactivation Code:
Reactivation Date:2019-01-08
Provider Licenses
StateLicense IDTaxonomies
MI43015112092080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
09920646OtherECFMG CERTIFICATION