Provider Demographics
NPI:1316333990
Name:MISHRA, MONIKA
Entity type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:MISHRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-576-5576
Mailing Address - Fax:203-576-5022
Practice Address - Street 1:1302 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1748
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT57006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT223160873OtherUNITED HEALTH CARE
CTD400489070OtherMEDICARE
CT6862292OtherCIGNA
CT6862292OtherAETNA
CT1316333990OtherCONNECTICARE
CT1316333990OtherANTHEM BCBS
CT008081148Medicaid