Healthcare Provider Details

I. General information

NPI: 1396893863
Provider Name (Legal Business Name): VINOD MISHRA MD FACG A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6958 BROCKTON AVE STE 201
RIVERSIDE CA
92506-3802
US

IV. Provider business mailing address

6958 BROCKTON AVE STE 201
RIVERSIDE CA
92506-3802
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-6790
  • Fax: 951-784-9919
Mailing address:
  • Phone: 951-784-6790
  • Fax: 951-784-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA38396
License Number StateCA

VIII. Authorized Official

Name: VINOD MISHRA
Title or Position: OWNER
Credential: MD
Phone: 951-784-6790