=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659614931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIMITRE MIRTCHEV M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2013
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6431 FANNIN ST SUITE 7.044
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-325-7080
-----------------------------------------------------
Fax | 713-512-2239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 ASYLUM AVE STE 4304
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06105-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-714-7509
-----------------------------------------------------
Fax | 860-714-8038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | 60330
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------