Provider Demographics
NPI:1164876157
Name:ELNAN, MIRA (MD)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:ELNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SHORELINE DR
Mailing Address - Street 2:UNIT 1262
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6450
Mailing Address - Country:US
Mailing Address - Phone:510-437-5039
Mailing Address - Fax:510-535-7313
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3143
Practice Address - Country:US
Practice Address - Phone:510-307-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152302207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program