Provider Demographics
NPI:1932171345
Name:MISHRA, SANJEEB K (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEB
Middle Name:K
Last Name:MISHRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10 SAINT PATRICKS DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4527
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:10 SAINT PATRICKS DR STE D
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4527
Practice Address - Country:US
Practice Address - Phone:301-645-8322
Practice Address - Fax:301-645-6229
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD23021207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD390003283OtherRAILROAD MEDICARE
MD018131500Medicaid
MD390003283OtherRAILROAD MEDICARE
MD018131500Medicaid
DC00A760S49Medicare PIN