Basic Information
| Provider Information | |||||||||
| NPI: | 1518133792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRAKA | ||||||||
| FirstName: | ALTIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31125 PORTSIDE DR | ||||||||
| Address2: | APT# 6206 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483774245 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11141 PARKVIEW PLAZA DR STE 320 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604255400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 5101019268 | MI | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 02005220A | IN | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.