Provider Demographics
NPI:1265685523
Name:HOM, MIRON J (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRON
Middle Name:J
Last Name:HOM
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 1:450 BAUCHET ST
Mailing Address - Street 2:S367, IRC-JAIL MH ADMIN
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2907
Mailing Address - Country:US
Mailing Address - Phone:213-473-6129
Mailing Address - Fax:
Practice Address - Street 1:450 BAUCHET ST
Practice Address - Street 2:S367, IRC-JAIL MH ADMIN
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2907
Practice Address - Country:US
Practice Address - Phone:213-473-6129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0636632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry