Basic Information
Provider Information | |||||||||
NPI: | 1003040403 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MIR | ||||||||
FirstName: | ADNAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1133 WESTCHESTER AVE STE 331 | ||||||||
Address2: |   | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106043516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009423376 | ||||||||
FaxNumber: | 9149349819 | ||||||||
Practice Location | |||||||||
Address1: | 1133 WESTCHESTER AVE STE 331 | ||||||||
Address2: |   | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106043516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009423376 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2009 | ||||||||
LastUpdateDate: | 01/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Q3555 | TX | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207NP0225X | Q3555 | TX | N |   | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207ND0900X | 263239 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
No ID Information.