Provider Demographics
NPI:1801930441
Name:MIRMIRAN, ALIREZA (MD)
Entity type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:MIRMIRAN
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:PO BOX 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:SUITE # LL6
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-4104
Practice Address - Fax:402-354-8761
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE251522085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025044300Medicaid
IA1801930441Medicaid
NE10025775900Medicaid
NE10025044300Medicaid
NE10025775900Medicaid