Healthcare Provider Details

I. General information

NPI: 1558363630
Provider Name (Legal Business Name): DANIEL SCOTT MIRKIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DANIEL MIRKIN OD

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 BEACH 116TH ST
ROCKAWAY PARK NY
11694-2102
US

IV. Provider business mailing address

253 BEACH 116TH ST
ROCKAWAY PARK NY
11694-2102
US

V. Phone/Fax

Practice location:
  • Phone: 718-634-0005
  • Fax: 718-474-2003
Mailing address:
  • Phone: 718-634-0005
  • Fax: 718-474-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT004688
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberVUT004688
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberVUT004688
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: