Provider Demographics
NPI:1295720522
Name:MIRRA, DENNIS R (O D)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:R
Last Name:MIRRA
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-5861
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000302622Medicaid
DE510292224OtherUNITED HEALTHCARE
DEP01245272OtherPALMETTO GBA RR MEDICARE PTAN GROUP 1245251313
DE4405500OtherAETNA
DE1603OtherCOVENTRY
DEB86041OtherDE BLUE CROSS
DE4405500OtherAETNA
DET26955Medicare UPIN