Healthcare Provider Details

I. General information

NPI: 1962488825
Provider Name (Legal Business Name): DR. SHYAM N MISHRA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 IRVING RD SUITE 200
STERLING HTS MI
48312-4614
US

IV. Provider business mailing address

8202 IRVING RD SUITE 200
STERLING HTS MI
48312-4614
US

V. Phone/Fax

Practice location:
  • Phone: 586-268-1990
  • Fax: 586-268-1991
Mailing address:
  • Phone: 586-268-1990
  • Fax: 586-268-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301032198
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: