Eugene Mirrer, MD – Dermatology Physician

Key facts

NPI: 1619070646
Entity type: Individual (NPI type 1)
Primary specialty: Dermatology Physician 207N00000X
License: 014739 (CT)
Practice address: 171 Grandview Ave
Suite 103
Waterbury, CT 06708-2517
Phone: (203) 757-8919
Fax: (203) 756-4697
NPI assigned: Sep 6, 2006
Sex: Male
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No
Credentials: Doctor of Medicine

State licenses

License	State	Type	Specialty
014739	CT	MD	Dermatology Physician

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Dermatology Physician	207N00000X	014739	CT	Yes

Addresses

Primary practice location

171 Grandview Ave
Suite 103
Waterbury, CT 06708-2517

Mailing address

171 Grandview Ave
Suite 103
Waterbury, CT 06708-2517
Phone (203) 757-8919

Other identifiers

Identifier	Type	State	Issuer
070000161	Other	CT	MEDICARE PROVIDER ID#
368	Other		ST CONTROLLED SUB

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Mar 7, 2023.

{
    "created_epoch": "1157500800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1619070646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "171 GRANDVIEW AVE",
            "address_2": "SUITE 103",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067082517",
            "telephone_number": "203-757-8919",
            "fax_number": "203-756-4697"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "171 GRANDVIEW AVE",
            "address_2": "SUITE 103",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067082517",
            "telephone_number": "203-757-8919",
            "fax_number": "203-756-4697"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MIRRER",
        "first_name": "EUGENE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-06",
        "last_updated": "2023-03-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "CT",
            "license": "014739",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER  ID#",
            "identifier": "070000161",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ST CONTROLLED SUB",
            "identifier": "368",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Waterbury, CT

All providers in Waterbury, CT · Dermatology Physician in Connecticut

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 7, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.