Healthcare Provider Details

I. General information

NPI: 1578441200
Provider Name (Legal Business Name): MIRA MACE MEDICAL SERVICES EAST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111B S GOVERNORS AVE STE 39475
DOVER DE
19904-6903
US

IV. Provider business mailing address

1111B S GOVERNORS AVE STE 39475
DOVER DE
19904-6903
US

V. Phone/Fax

Practice location:
  • Phone: 332-296-0021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PRASHANT KUMAR
Title or Position: OPERATIONS ADMINISTRATOR
Credential:
Phone: 332-296-0021