Provider Demographics
NPI:1558363630
Name:MIRKIN, DANIEL SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SCOTT
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:MIRKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:253 BEACH 116TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2102
Mailing Address - Country:US
Mailing Address - Phone:718-634-0005
Mailing Address - Fax:718-474-2003
Practice Address - Street 1:253 BEACH 116TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2102
Practice Address - Country:US
Practice Address - Phone:718-634-0005
Practice Address - Fax:718-474-2003
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004688152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP90652OtherAETNA
1558363630OtherGROUP MEMBER NPI
G400012756OtherGROUP MEMBER PTAN
P824790OtherOXFORD
NY01126778Medicaid
NYDM0C408810OtherBLUE SHIELD
G400012756OtherGROUP MEMBER PTAN
1558363630OtherGROUP MEMBER NPI
NY0206820001Medicare NSC