Healthcare Provider Details

I. General information

NPI: 1619940277
Provider Name (Legal Business Name): MATTHEW MIRIANI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 DORSETT VLG
MARYLAND HEIGHTS MO
63043-2208
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-0550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7H77
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: