Provider Demographics
NPI:1265298756
Name:MIRAGE MEDICAL GROUP
Entity type:Organization
Organization Name:MIRAGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ZORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBAKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-346-4003
Mailing Address - Street 1:44650 VILLAGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3812
Mailing Address - Country:US
Mailing Address - Phone:760-346-4003
Mailing Address - Fax:
Practice Address - Street 1:44650 VILLAGE CT STE 100
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3812
Practice Address - Country:US
Practice Address - Phone:760-346-4003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty