Basic Information
| Provider Information | |||||||||
| NPI: | 1033154448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGANOVIC | ||||||||
| FirstName: | MIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8220 WYMARK DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957570000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166670600 | ||||||||
| FaxNumber: | 9166830232 | ||||||||
| Practice Location | |||||||||
| Address1: | 8220 WYMARK DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957570000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166670600 | ||||||||
| FaxNumber: | 9166830232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 001720 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02353464 | 05 | NY | MEDICAID |