Provider Demographics
NPI:1609850700
Name:GIACONI, MIRKO ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MIRKO
Middle Name:ANDREW
Last Name:GIACONI
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 1:1600 S GAFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4628
Mailing Address - Country:US
Mailing Address - Phone:310-548-0201
Mailing Address - Fax:310-548-4492
Practice Address - Street 1:1600 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4628
Practice Address - Country:US
Practice Address - Phone:310-548-0201
Practice Address - Fax:310-548-4492
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25678207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A256780Medicaid
A24533Medicare UPIN
CAWA25678AMedicare PIN
CA00A256780Medicaid