Provider Demographics
NPI:1053303222
Name:MIRRO, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MIRRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-266-8213
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025414A207RC0000X, 207RC0001X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100138540Medicaid
IN000000641091OtherANTHEM
IN060070554OtherRR MEDICARE
OH0509079Medicaid
INP00782366OtherR.R. MEDICARE
IN060070554Medicare PIN
IN000000641091OtherANTHEM
INP00782366OtherR.R. MEDICARE
IN193580LMedicare PIN
IN060070554OtherRR MEDICARE