Provider Demographics
NPI:1659424026
Name:MIRA, ESTELLA (OD)
Entity Type:Individual
Prefix:
First Name:ESTELLA
Middle Name:
Last Name:MIRA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 STATE ROUTE 34 STE F
Mailing Address - Street 2:MARKETPLACE MALL
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-9506
Mailing Address - Country:US
Mailing Address - Phone:732-583-3600
Mailing Address - Fax:732-583-3770
Practice Address - Street 1:443 STATE ROUTE 34 STE F
Practice Address - Street 2:MARKETPLACE MALL
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9506
Practice Address - Country:US
Practice Address - Phone:732-583-3600
Practice Address - Fax:732-583-3770
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00507200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist