Provider Demographics
NPI:1972615631
Name:MIRRA, MARTIN C (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:C
Last Name:MIRRA
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1333 TAYLOR STREET
Practice Address - Street 2:STE 3A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-254-4707
Practice Address - Fax:803-254-1198
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC196709Medicaid
SCH57137Medicare UPIN
SC196709Medicaid
SCH571376718Medicare PIN
SCSC31555925Medicare PIN