Healthcare Provider Details

I. General information

NPI: 1780811034
Provider Name (Legal Business Name): JOHN C. MIRMANESH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2009
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 LINCOLN DR W STE 311
MARLTON NJ
08053-3405
US

IV. Provider business mailing address

12000 LINCOLN DR W STE 311
MARLTON NJ
08053-3405
US

V. Phone/Fax

Practice location:
  • Phone: 856-985-8100
  • Fax: 856-985-0178
Mailing address:
  • Phone: 856-985-8100
  • Fax: 856-985-0178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP24028
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: