Basic Information
| Provider Information | |||||||||
| NPI: | 1295720522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRRA | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | O. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 01/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | I3-0001149 | DE | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0000302622 | 05 | DE | MEDICAID | 510292224 | 01 | DE | UNITED HEALTHCARE | OTHER | P01245272 | 01 | DE | PALMETTO GBA RR MEDICARE PTAN GROUP 1245251313 | OTHER | 4405500 | 01 | DE | AETNA | OTHER | 1603 | 01 | DE | COVENTRY | OTHER | B86041 | 01 | DE | DE BLUE CROSS | OTHER |