Provider Demographics
NPI:1407013840
Name:SIVAN, MIRA KALMAN (OD)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:KALMAN
Last Name:SIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CREEK RUN CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4374
Mailing Address - Country:US
Mailing Address - Phone:770-752-9501
Mailing Address - Fax:
Practice Address - Street 1:5462 MEMORIAL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3239
Practice Address - Country:US
Practice Address - Phone:404-296-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist