MEDICARE: DURBA MISHRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	L0429	TX
2	207QA0000X	Adolescent Medicine (Family Medicine) Physician	L0429	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588673008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DURBA MISHRA MD

Provider Business Mailing Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Provider Business Practice Location Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	09/12/2023

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Directions to “ DURBA MISHRA MD” Practice Location

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