Healthcare Provider Details

I. General information

NPI: 1497359764
Provider Name (Legal Business Name): KEVIN MIJARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

1901 1ST AVE
NEW YORK NY
10029-7494
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6810
  • Fax: 212-423-7656
Mailing address:
  • Phone: 212-423-6810
  • Fax: 212-423-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number337229
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: