Basic Information
| Provider Information | |||||||||
| NPI: | 1740662691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRIELLO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | GRAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5505 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421705 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 N WINSTEAD AVE STE 190 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278048712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529377777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | OPT002870 | GA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2443 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.