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General NPI Number Information
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NPI Number | 1750398491
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Entity Type | Organization
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Legal Business Name | MIRKO A GIACONI MD INC
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 02/28/2013
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Provider Practice Location Address
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Address Line | 1360 WEST 6TH ST STE 205
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City | SAN PEDRO
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State | CA
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Zip | 90732
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Country | US
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Telephone | 310-832-7541
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Fax | 310-832-3585
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Provider Business Mailing Address
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Address Line | 1360 WEST 6TH ST STE 205
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City | SAN PEDRO
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State | CA
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Zip | 90732
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Country | US
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Telephone | 310-832-7541
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Fax | 310-832-3585
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Authorized Official
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Title or Position | PRESIDENT
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Name | MIRKO ANDREW GIACONI
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Credential | MD
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Telephone | 310-832-7541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | A25678
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License Number State | CA
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