Provider Demographics
NPI:1053765545
Name:MIRANDA MEDICAL, PLLC
Entity type:Organization
Organization Name:MIRANDA MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:A RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-420-1319
Mailing Address - Street 1:PO BOX 5498
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-5498
Mailing Address - Country:US
Mailing Address - Phone:208-736-8006
Mailing Address - Fax:208-329-7159
Practice Address - Street 1:706 N COLLEGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5824
Practice Address - Country:US
Practice Address - Phone:208-736-8006
Practice Address - Fax:208-329-7159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9799207RH0003X
ORMD151354207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty