Provider Demographics
NPI:1164784450
Name:MIROSHNICHENKO, GENNADY G (MD)
Entity Type:Individual
Prefix:
First Name:GENNADY
Middle Name:G
Last Name:MIROSHNICHENKO
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:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-8450
Mailing Address - Fax:
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4804
Practice Address - Country:US
Practice Address - Phone:817-702-6500
Practice Address - Fax:817-702-6561
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4595207V00000X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307460101Medicaid
TX8DM684OtherBCBS
TXTXB165031Medicare PIN