Provider Demographics
NPI:1912949256
Name:MIRKIN, IRENE R (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:R
Last Name:MIRKIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:608-417-6000
Mailing Address - Fax:
Practice Address - Street 1:7780 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-5407
Practice Address - Country:US
Practice Address - Phone:608-417-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31391800Medicaid
1000324OtherPPIC PROVIDER #
WI31391800Medicaid