Healthcare Provider Details

I. General information

NPI: 1801930441
Provider Name (Legal Business Name): ALIREZA MIRMIRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST SUITE # LL6
OMAHA NE
68114-4108
US

IV. Provider business mailing address

PO BOX 10190
VIRGINIA BEACH VA
23450-0190
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-4104
  • Fax: 402-354-8761
Mailing address:
  • Phone: 800-477-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25152
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: