Provider Demographics
NPI:1538285069
Name:MIRIAN, MIRFATTAH (DPM)
Entity Type:Individual
Prefix:
First Name:MIRFATTAH
Middle Name:
Last Name:MIRIAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 S LONG DR
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-4315
Mailing Address - Country:US
Mailing Address - Phone:910-997-3779
Mailing Address - Fax:910-997-7433
Practice Address - Street 1:721 S LONG DR
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-4315
Practice Address - Country:US
Practice Address - Phone:910-997-3779
Practice Address - Fax:910-997-7433
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC250213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890812AMedicaid
NC243131Medicare PIN
T64088Medicare UPIN
NCCJ4317Medicare PIN