Healthcare Provider Details

I. General information

NPI: 1851577241
Provider Name (Legal Business Name): VIJAY MIRMIRA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W KETTLEMAN LN SUITE 200
LODI CA
95242-4337
US

IV. Provider business mailing address

PO BOX 241011
LODI CA
95241-9511
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-8540
  • Fax: 209-368-2885
Mailing address:
  • Phone: 209-339-7825
  • Fax: 209-339-7528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA106428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: