Provider Demographics
NPI:1629347182
Name:MIRAKOV, SERGEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:
Last Name:MIRAKOV
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 1:1400 BLACKHORSE HILL ROAD
Mailing Address - Street 2:BLDG 39, ROOMB06G
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320
Mailing Address - Country:US
Mailing Address - Phone:610-384-7711
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKHORSE HILL ROAD
Practice Address - Street 2:BLDG 39, ROOMB06G
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320
Practice Address - Country:US
Practice Address - Phone:610-384-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4608542084P0800X, 2084P0802X
PAMT204799390200000X
FLME1388272084P0802X
UT10276247-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program