Healthcare Provider Details

I. General information

NPI: 1942206511
Provider Name (Legal Business Name): MIR KIBRIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 516-562-4887
  • Fax:
Mailing address:
  • Phone: 516-945-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0060360
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier402286600
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: