Provider Demographics
NPI:1891761623
Name:MIRKOVICH, JOSEPH N JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:N
Last Name:MIRKOVICH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6521 VIA LORENZO
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6543
Mailing Address - Country:US
Mailing Address - Phone:323-842-2658
Mailing Address - Fax:888-235-1709
Practice Address - Street 1:7500 HELLMAN AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2216
Practice Address - Country:US
Practice Address - Phone:626-288-1160
Practice Address - Fax:626-371-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN391852084P0800X
CAA779302084P0800X
CA779302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A779300Medicaid
CABY296AMedicare PIN