Provider Demographics
NPI:1861045502
Name:MIRONOV, LIANA (OD)
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:MIRONOV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 COLERIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4106
Mailing Address - Country:US
Mailing Address - Phone:917-573-6114
Mailing Address - Fax:
Practice Address - Street 1:18 HEYWARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-9210
Practice Address - Country:US
Practice Address - Phone:917-573-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPFC93152W00000X
NYTUV008953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist