Basic Information
| Provider Information | |||||||||
| NPI: | 1295815439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIR | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23331 EL TORO RD | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926304891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499169100 | ||||||||
| FaxNumber: | 9499887551 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 ODYSSEY SUITE 115 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499887550 | ||||||||
| FaxNumber: | 9499887551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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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 | 207Q00000X | A96676 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.