Gerard Matthew Mirkov, DMD

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

17326 Issued in NJ

Practice address

89 Park Street
Montclair, NJ 07042

Phone

(973) 746-6200

Fax

(973) 744-3114

NPI assigned

Apr 16, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NJ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176681600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1720203847",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "89 PARK STREET",
            "city": "MONTCLAIR",
            "state": "NJ",
            "postal_code": "07042",
            "telephone_number": "973-746-6200",
            "fax_number": "973-744-3114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "89 PARK STREET",
            "city": "MONTCLAIR",
            "state": "NJ",
            "postal_code": "07042",
            "telephone_number": "973-746-6200",
            "fax_number": "973-744-3114"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MIRKOV",
        "first_name": "GERARD",
        "middle_name": "MATTHEW",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-04-16",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "17326",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5619904",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Oral and Maxillofacial Surgery (Dentist) in Montclair, NJ
• Providers in Montclair, NJ by specialty
• Oral and Maxillofacial Surgery (Dentist) in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.