Basic Information
| Provider Information | |||||||||
| NPI: | 1003803594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISHRA | ||||||||
| FirstName: | UMA | ||||||||
| MiddleName: | BALLAVA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2565 ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455344700 | ||||||||
| FaxNumber: | 8455344800 | ||||||||
| Practice Location | |||||||||
| Address1: | 2565 ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455344700 | ||||||||
| FaxNumber: | 8455344800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1356911 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00960843 | 05 | NY | MEDICAID |