Individual
GENNADY G MIROSHNICHENKO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1201 S MAIN ST, FORT WORTH, TX 76104-4804
(817) 702-6500
(817) 702-6561
Mailing address
PO BOX 732973, DALLAS, TX 75373-2973
(817) 702-8450
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
P4595
TX
207VX0201X
Gynecologic Oncology Physician
Primary
P4595
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
307460101
—
TX
01
—
8DM684
BCBS
TX
Enumeration date
06/12/2012
Last updated
02/01/2021
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