Provider Demographics
NPI:1558473629
Name:MIRKINSON, SUSAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:MIRKINSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1000 NORTHERN BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5312
Mailing Address - Country:US
Mailing Address - Phone:516-627-4433
Mailing Address - Fax:516-627-0552
Practice Address - Street 1:1000 NORTHERN BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5312
Practice Address - Country:US
Practice Address - Phone:516-627-4433
Practice Address - Fax:516-627-0552
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY181084-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0170157OtherGHI
0599536OtherCIGNA
6C1347OtherHEALTHNET
SM0678AK10OtherBLUE SHIELD
NY11820POtherHIP
NY25992OtherAETNA USHC
1623355OtherAETNA
NY30703OtherVYTRA
NYAP433OtherOXFORD
389551OtherVYTRA
181084OtherHIP
181084Other1199
NY78F701OtherBCBS
6C1347OtherHEALTHNET
0599536OtherCIGNA