Healthcare Provider Details

I. General information

NPI: 1164475877
Provider Name (Legal Business Name): VIJAY LAXMI MISRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 TOWANDA AVE STE 1
BLOOMINGTON IL
61701-3469
US

IV. Provider business mailing address

1228 TOWANDA AVE STE 1
BLOOMINGTON IL
61701-3469
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-5900
  • Fax: 309-454-2820
Mailing address:
  • Phone: 309-454-5900
  • Fax: 309-454-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036126566
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: