Provider Demographics
NPI:1376550418
Name:MIRKIN, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:918 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2704
Practice Address - Country:US
Practice Address - Phone:512-404-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG75542083T0002X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical Toxicology
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288126Medicaid
OR0185217OtherWA L&I
WA140582OtherWA L&I
OR0185217OtherWA L&I
WAAB17267Medicare ID - Type Unspecified