Provider Demographics
NPI:1952758096
Name:SHISRAM, UNKNOWN (MSCMH, DSM, DMH)
Entity Type:Individual
Prefix:MR
First Name:UNKNOWN
Middle Name:
Last Name:SHISRAM
Suffix:
Gender:M
Credentials:MSCMH, DSM, DMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX LBJ
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-9994
Mailing Address - Country:US
Mailing Address - Phone:684-633-1222
Mailing Address - Fax:684-633-2893
Practice Address - Street 1:96799 TURNER DRIVE
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799-9994
Practice Address - Country:US
Practice Address - Phone:684-633-1222
Practice Address - Fax:684-633-2893
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS2182-C2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry