MEDICARE: DR. DANIEL SCOTT MIRKIN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	VUT004688	NY
2	152WC0802X	Corneal and Contact Management Optometrist	VUT004688	NY
3	152WP0200X	Pediatric Optometrist	VUT004688	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OP90652	OTHER		AETNA
2	1558363630	OTHER		GROUP MEMBER NPI
3	G400012756	OTHER		GROUP MEMBER PTAN
4	P824790	OTHER		OXFORD
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	DM0C408810	OTHER	NY	BLUE SHIELD

General Provider Information

NPI Number	:	1558363630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL SCOTT MIRKIN OD

Provider Business Mailing Address
First Line	:	253 BEACH 116TH ST
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2102
Country	:	US
Telephone Number	:	718-634-0005
Fax Number	:	718-474-2003

Provider Business Practice Location Address
First Line	:	253 BEACH 116TH ST
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2102
Country	:	US
Telephone Number	:	718-634-0005
Fax Number	:	718-474-2003

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	10/25/2011

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