Provider Demographics
NPI:1053949099
Name:MIRO, EMILY W (MD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:W
Last Name:MIRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:E
Other - Last Name:WOLFENDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 S CHIPETA WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1261
Mailing Address - Country:US
Mailing Address - Phone:801-581-8250
Mailing Address - Fax:
Practice Address - Street 1:375 S CHIPETA WAY STE A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1261
Practice Address - Country:US
Practice Address - Phone:801-581-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12409790-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine