Basic Information
| Provider Information | |||||||||
| NPI: | 1972581924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISHRA | ||||||||
| FirstName: | KAMLA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 82 TUNNEL RD | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706225455 | ||||||||
| FaxNumber: | 5706225493 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 SCHUYLKILL MANOR RD | ||||||||
| Address2: | SUITE 5A | ||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705169444 | ||||||||
| FaxNumber: | 5707282360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD059125L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0015971720002 | 05 | PA | MEDICAID | 50070589 | 01 | PA | KEYSTONE SPECIALIST | OTHER | 50070589 | 01 | PA | KEYSTONE | OTHER | CB00663 | 01 | PA | RAILROAD MEDICARE PBA | OTHER | 0015971720004 | 01 | PA | MA | OTHER |