1891761623 NPI number — DR. JOSEPH N MIRKOVICH JR. M.D.

Table of content: DR. JOSEPH N MIRKOVICH JR. M.D. (NPI 1891761623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891761623 NPI number — DR. JOSEPH N MIRKOVICH JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRKOVICH
Provider First Name:
JOSEPH
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891761623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6521 VIA LORENZO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO PALOS VERDES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90275-6543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-842-2658
Provider Business Mailing Address Fax Number:
888-235-1709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 HELLMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEMEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91770-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-288-1160
Provider Business Practice Location Address Fax Number:
626-371-1320
Provider Enumeration Date:
02/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  39185 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: A77930 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 77930 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A779300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".