Provider Demographics
NPI:1891760682
Name:MIRWALD, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MIRWALD
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 1:310 EXCHANGE BLVD.
Mailing Address - Street 2:APT. 158
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2164
Mailing Address - Country:US
Mailing Address - Phone:585-225-6680
Mailing Address - Fax:585-225-3472
Practice Address - Street 1:120 ERIE CANAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4607
Practice Address - Country:US
Practice Address - Phone:585-225-6680
Practice Address - Fax:585-225-3472
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124283207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB72227Medicare UPIN