Healthcare Provider Details

I. General information

NPI: 1467866897
Provider Name (Legal Business Name): ALEXANDER MIRONOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 GREAT NECK RD
GREAT NECK NY
11021-4315
US

IV. Provider business mailing address

630 W 168TH ST # 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-6747
  • Fax:
Mailing address:
  • Phone: 212-305-5996
  • Fax: 212-305-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number293403
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number293403
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: