Provider Demographics
NPI:1972591253
Name:MIURA, DENNIS S (MD PHD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:S
Last Name:MIURA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 JARRET PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2606
Mailing Address - Country:US
Mailing Address - Phone:718-518-1276
Mailing Address - Fax:718-518-1281
Practice Address - Street 1:1521 JARRET PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2606
Practice Address - Country:US
Practice Address - Phone:718-518-1276
Practice Address - Fax:718-518-1281
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00532825Medicaid
NY37A112Medicare ID - Type Unspecified
NY00532825Medicaid