Provider Demographics
NPI:1336330026
Name:V MIROSHNICHENKO DPM PA
Entity Type:Organization
Organization Name:V MIROSHNICHENKO DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MIROSHNICHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-721-1990
Mailing Address - Street 1:8333 W MCNAB RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3242
Mailing Address - Country:US
Mailing Address - Phone:954-721-1990
Mailing Address - Fax:954-721-1932
Practice Address - Street 1:8333 W MCNAB RD
Practice Address - Street 2:SUITE 116
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3242
Practice Address - Country:US
Practice Address - Phone:954-721-1990
Practice Address - Fax:954-721-1932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2442213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP148OtherMEDICARE PTAN
FLAP148OtherMEDICARE PTAN