Provider Demographics
NPI:1073856019
Name:MIRO, VIKTOR (MD)
Entity Type:Individual
Prefix:
First Name:VIKTOR
Middle Name:
Last Name:MIRO
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 1:1200 MAIN ST APT 2309
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-4311
Mailing Address - Country:US
Mailing Address - Phone:347-525-7203
Mailing Address - Fax:
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:260-266-2020
Practice Address - Fax:812-944-7701
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305464207R00000X
IN01078521A207R00000X
MEMD24890208M00000X
TXQ7582208M00000X
TN59974208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8LV207OtherBCBS