Healthcare Provider Details

I. General information

NPI: 1205418589
Provider Name (Legal Business Name): SHIV KUMAR MISRA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

400 ASSOCIATION DR STE 102
CHARLESTON WV
25311-1298
US

V. Phone/Fax

Practice location:
  • Phone: 740-374-7700
  • Fax: 740-374-7701
Mailing address:
  • Phone: 304-760-7536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34.017777
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4621
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4621
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number34.017777
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4621
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: