Healthcare Provider Details

I. General information

NPI: 1336330026
Provider Name (Legal Business Name): V MIROSHNICHENKO DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8333 W MCNAB RD SUITE 116
TAMARAC FL
33321-3242
US

IV. Provider business mailing address

8333 W MCNAB RD SUITE 116
TAMARAC FL
33321-3242
US

V. Phone/Fax

Practice location:
  • Phone: 954-721-1990
  • Fax: 954-721-1932
Mailing address:
  • Phone: 954-721-1990
  • Fax: 954-721-1932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2442
License Number StateFL

VIII. Authorized Official

Name: DR. VICTOR MIROSHNICHENKO
Title or Position: PRESIDENT / OWNER
Credential: D.P.M.
Phone: 954-721-1990