Provider Demographics
NPI:1851577241
Name:MIRMIRA, VIJAY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:MIRMIRA
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:PO BOX 241011
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-9511
Mailing Address - Country:US
Mailing Address - Phone:209-339-7825
Mailing Address - Fax:209-339-7528
Practice Address - Street 1:1901 W KETTLEMAN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4337
Practice Address - Country:US
Practice Address - Phone:209-334-8540
Practice Address - Fax:209-368-2885
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR01409Medicare PIN
IL216239Medicare UPIN