Provider Demographics
NPI:1740276310
Name:MISHR, SUMAN K (MD)
Entity type:Individual
Prefix:DR
First Name:SUMAN
Middle Name:K
Last Name:MISHR
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 1:306 REICHELDERFER RD
Mailing Address - Street 2:
Mailing Address - City:CRIDERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45806-2252
Mailing Address - Country:US
Mailing Address - Phone:419-645-4343
Mailing Address - Fax:419-645-4443
Practice Address - Street 1:306 REICHELDERFER RD
Practice Address - Street 2:
Practice Address - City:CRIDERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45806-2252
Practice Address - Country:US
Practice Address - Phone:419-645-4343
Practice Address - Fax:419-645-4443
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-10-01
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
OH041221207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1053365882OtherGROUP NPI AFFILIATION
OH0360416Medicaid
OH1053365882OtherGROUP NPI AFFILIATION
OHMI4091345Medicare PIN