MEDICARE: DYSHAI MIMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372600000X	Adult Companion	NA9988429	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598281503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYSHAI MIMS

Provider Business Mailing Address
First Line	:	57 EASTWOOD RD
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06606-1409
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	182 HANOVER ST
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06604-3706
Country	:	US
Telephone Number	:	203-572-6265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	08/21/2017

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Directions to “ DYSHAI MIMS ” Practice Location

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