Provider Demographics
NPI:1871661132
Name:MIRKIN, BRUCE DAVID
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DAVID
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5280
Mailing Address - Country:US
Mailing Address - Phone:516-766-2800
Mailing Address - Fax:516-766-0222
Practice Address - Street 1:28 S PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5280
Practice Address - Country:US
Practice Address - Phone:516-766-2800
Practice Address - Fax:516-766-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004817-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4705220001Medicare NSC