Healthcare Provider Details

I. General information

NPI: 1689797847
Provider Name (Legal Business Name): MAXIM V MIROVSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GRESHAM DR 907 MEDICAL TOWER
NORFOLK VA
23507-1901
US

IV. Provider business mailing address

6160 KEMPSVILLE CIRCLE SUITE 302A
NORFOLK VA
23502
US

V. Phone/Fax

Practice location:
  • Phone: 757-627-7301
  • Fax: 757-627-6238
Mailing address:
  • Phone: 757-466-9288
  • Fax: 757-466-8954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101840366
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: