Healthcare Provider Details

I. General information

NPI: 1144325622
Provider Name (Legal Business Name): NICOLE AUTUMN MIRJAFARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE AUTUMN SMITH MD

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD STE 1B
LIVERPOOL NY
13088-3808
US

IV. Provider business mailing address

5100 W TAFT RD STE 1B
LIVERPOOL NY
13088-3808
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9888
  • Fax: 239-303-0714
Mailing address:
  • Phone: 918-406-2024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number324770
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ0568
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24093
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME138382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: