MEDICARE: GARY MIRKIN MD

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	208000000X	Pediatrics Physician	155187	NY

General Provider Information

NPI Number	:	1982664421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY MIRKIN MD

Provider Business Mailing Address
First Line	:	68 S SERVICE RD
Second Line	:	SUITE 350
City	:	MELVILLE
State	:	NY
Zip	:	11747-2354
Country	:	US
Telephone Number	:	516-945-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	935 NORTHERN BLVD
Second Line	:	SUITE 300
City	:	GREAT NECK
State	:	NY
Zip	:	11021-5309
Country	:	US
Telephone Number	:	516-466-5437
Fax Number	:

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	11/12/2009

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