Provider Demographics
NPI:1730173493
Name:MIRMOW, DWIGHT PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:PAUL
Last Name:MIRMOW
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 1:2321 KINGS WAY
Mailing Address - Street 2:LABORATORY MEDICINE, PC
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904
Mailing Address - Country:US
Mailing Address - Phone:706-481-7473
Mailing Address - Fax:706-481-7868
Practice Address - Street 1:2260 LURIGHTSBORO RD
Practice Address - Street 2:LABORATORY MEDICINE, PC
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:706-481-7473
Practice Address - Fax:706-481-7868
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048805207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202I223645Medicare PIN
GAP00373827Medicare PIN
SCG65977Medicare UPIN
GAG65977Medicare UPIN
SC7399Medicare PIN
GA22BDDCMMedicare PIN