Provider Demographics
NPI:1316022411
Name:MIROT, MAX S (MD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:S
Last Name:MIROT
Suffix:
Gender:M
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0609
Mailing Address - Country:US
Mailing Address - Phone:520-335-1800
Mailing Address - Fax:520-335-2743
Practice Address - Street 1:300 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2812
Practice Address - Country:US
Practice Address - Phone:520-335-1800
Practice Address - Fax:520-335-2743
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47745207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ907844Medicaid
AZZ163670Medicare PIN
G42081Medicare UPIN
001322050Medicare PIN
G42081Medicare UPIN
WI32728700Medicaid