Provider Demographics
NPI:1174588768
Name:MISRA, SURESH K (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:K
Last Name:MISRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3267 S 16TH STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215
Mailing Address - Country:US
Mailing Address - Phone:414-643-7448
Mailing Address - Fax:
Practice Address - Street 1:3267 S 16TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4500
Practice Address - Country:US
Practice Address - Phone:414-643-7448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30156400Medicaid
080172544OtherRR MEDICARE
080172544OtherRR MEDICARE
WI30156400Medicaid