Provider Demographics
NPI:1144325622
Name:MIRJAFARI, NICOLE AUTUMN (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:AUTUMN
Last Name:MIRJAFARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:AUTUMN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5100 W TAFT RD STE 1B
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3808
Mailing Address - Country:US
Mailing Address - Phone:918-406-2024
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD STE 1B
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3808
Practice Address - Country:US
Practice Address - Phone:239-343-9888
Practice Address - Fax:239-303-0714
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324770208000000X
TXQ0568208000000X
OK24093208000000X
FLME138382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104889000Medicaid
OK100768880FMedicaid
OK100768880IMedicaid