Provider Demographics
NPI:1558772186
Name:MIRMANESH, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:MIRMANESH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9575
Mailing Address - Country:US
Mailing Address - Phone:856-282-1338
Mailing Address - Fax:
Practice Address - Street 1:100 ROUTE 73
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9575
Practice Address - Country:US
Practice Address - Phone:856-282-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0013021208200000X
CA141171208200000X
PAMD466542208200000X
NJ25MA10070800208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery