Provider Demographics
NPI:1184660003
Name:MIRICA, MARILENA (MD)
Entity type:Individual
Prefix:DR
First Name:MARILENA
Middle Name:
Last Name:MIRICA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 E MAIN ST BLDG C
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2847
Mailing Address - Country:US
Mailing Address - Phone:631-418-8069
Mailing Address - Fax:631-656-0470
Practice Address - Street 1:267 E MAIN ST BLDG C
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2847
Practice Address - Country:US
Practice Address - Phone:631-418-8069
Practice Address - Fax:631-656-0470
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
32X211Medicare PIN