Individual
POONAM MISHRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
401 N WICKHAM RD, SUITE H, MELBOURNE, FL 32935-8659
(321) 757-5105
(321) 757-5104
Mailing address
401 N WICKHAM RD, SUITE H, MELBOURNE, FL 32935-8659
(321) 757-5105
(321) 757-5104
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
Primary
593360315
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
40462
BCBS MAB GROUP
FL
01
—
57174
BCBS PROVIDER ID
FL
Enumeration date
10/25/2005
Last updated
02/06/2015
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