Provider Demographics
NPI:1184896789
Name:MIRONOV, ANGEL (MD)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:MIRONOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CALIFORNIA PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68178-0133
Mailing Address - Country:US
Mailing Address - Phone:402-449-4540
Mailing Address - Fax:
Practice Address - Street 1:601 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2137
Practice Address - Country:US
Practice Address - Phone:402-449-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1962085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092239Medicare PIN
NE092239001Medicare PIN