Provider Demographics
NPI:1760589816
Name:MIRON, RICHARD V (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:V
Last Name:MIRON
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 1:10 GATEHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-2856
Mailing Address - Country:US
Mailing Address - Phone:413-253-1250
Mailing Address - Fax:413-253-1255
Practice Address - Street 1:505 NASHUA RD 7
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-1929
Practice Address - Country:US
Practice Address - Phone:978-674-0271
Practice Address - Fax:978-674-0279
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2036576Medicaid
MAB26218OtherBLUE CROSS BLUE SHIELD
MAB26218Medicare ID - Type Unspecified
MAB26218OtherBLUE CROSS BLUE SHIELD