Provider Demographics
NPI:1831253327
Name:MIRON, DOMINIC A (OD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:A
Last Name:MIRON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 10TH LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7032
Mailing Address - Country:US
Mailing Address - Phone:507-282-7121
Mailing Address - Fax:507-285-0951
Practice Address - Street 1:3632 10TH LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7032
Practice Address - Country:US
Practice Address - Phone:507-282-7121
Practice Address - Fax:507-285-0951
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2746152W00000X
IA02338152W00000X
WI2755-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN639544900Medicaid