Provider Demographics
NPI:1942241021
Name:AUBUCHON, MIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:AUBUCHON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:GOPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:17300 N OUTER 40 ROAD, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-779-9899
Mailing Address - Fax:636-778-9915
Practice Address - Street 1:17300 N OUTER 40 ROAD, SUITE 101
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:636-779-9899
Practice Address - Fax:636-778-9915
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086756207V00000X, 207VC0200X, 207VE0102X, 207VG0400X, 207VX0000X
KY39746207V00000X, 207VC0200X, 207VE0102X, 207VG0400X, 207VX0000X
MO2009007865207VE0102X, 207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care Medicine
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64105794Medicaid
OH2600788Medicaid
OH2600788Medicaid
MO152360087Medicare PIN
KY64105794Medicaid