Provider Demographics
NPI:1891776274
Name:MIRIN, BABAK (MD)
Entity Type:Individual
Prefix:
First Name:BABAK
Middle Name:
Last Name:MIRIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BABAK
Other - Middle Name:
Other - Last Name:MIRIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-622-8170
Mailing Address - Fax:
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-622-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM200200762084P0805X, 2084A0401X
NM2002-0076174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No174400000XOther Service ProvidersSpecialist
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34876855Medicaid