Provider Demographics
NPI:1063489912
Name:MIRETSKY, DONALD JAN (MED)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JAN
Last Name:MIRETSKY
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91258
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85752-1258
Mailing Address - Country:US
Mailing Address - Phone:520-744-6637
Mailing Address - Fax:
Practice Address - Street 1:7225 N PASEO DEL NORTE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4412
Practice Address - Country:US
Practice Address - Phone:520-744-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health