Provider Demographics
NPI:1780811034
Name:MIRMANESH, JOHN C (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:MIRMANESH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12000 LINCOLN DR W STE 311
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3405
Mailing Address - Country:US
Mailing Address - Phone:856-985-8100
Mailing Address - Fax:856-985-0178
Practice Address - Street 1:12000 LINCOLN DR W STE 311
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3405
Practice Address - Country:US
Practice Address - Phone:856-985-8100
Practice Address - Fax:856-985-0178
Is Sole Proprietor?:No
Enumeration Date:2009-06-14
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP24028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics