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General NPI Number Information
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NPI Number | 1265298756
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Entity Type | Organization
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Legal Business Name | MIRAGE MEDICAL GROUP
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Dates
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Enumeration Date | 02/22/2024
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Last Update Date | 02/22/2024
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Provider Practice Location Address
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Address Line | 44650 VILLAGE CT STE 100
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City | PALM DESERT
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State | CA
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Zip | 92260-3812
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Country | US
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Telephone | 760-346-4003
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Fax |
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Provider Business Mailing Address
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Address Line | 44650 VILLAGE CT STE 100
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City | PALM DESERT
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State | CA
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Zip | 92260-3812
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Country | US
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Telephone | 760-346-4003
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ZORAN RUBAKOVICH
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Credential |
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Telephone | 760-346-4003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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