Basic Information
| Provider Information | |||||||||
| NPI: | 1740600048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIREKU | ||||||||
| FirstName: | KENYATTA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 771 OLD NORCROSS RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300464981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709625040 | ||||||||
| FaxNumber: | 7709625056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 080834 | GA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.