Healthcare Provider Details

I. General information

NPI: 1275624157
Provider Name (Legal Business Name): BARUNI MISHRA SAMAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEADE PKWY
SUFFOLK VA
23434-4259
US

IV. Provider business mailing address

2000 MEADE PKWY
SUFFOLK VA
23434-4259
US

V. Phone/Fax

Practice location:
  • Phone: 757-539-0251
  • Fax: 757-539-8008
Mailing address:
  • Phone: 757-539-0251
  • Fax: 757-539-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101053131
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: