Provider Demographics
NPI:1497754790
Name:MIRRO, BETTY J (MD)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:J
Last Name:MIRRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:J
Other - Last Name:VAN HOOSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3085 FOUNTAINSIDE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7842
Mailing Address - Country:US
Mailing Address - Phone:901-755-0550
Mailing Address - Fax:901-755-0474
Practice Address - Street 1:3085 FOUNTAINSIDE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7842
Practice Address - Country:US
Practice Address - Phone:901-755-0550
Practice Address - Fax:901-755-0474
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370933Medicaid
TN621756596OtherTAX ID#
TN621756596OtherTAX ID#
TN3370933Medicaid