=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285668921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABHA MISHRA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 06/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1340 BROAD AVE STE 440
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-2460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-867-4855
-----------------------------------------------------
Fax | 228-867-4870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 753 E SCENIC DR
-----------------------------------------------------
City | PASS CHRISTIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39571-4620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-452-6121
-----------------------------------------------------
Fax | 228-452-6121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD035978
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 0101239395
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 19797
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------