Healthcare Provider Details

I. General information

NPI: 1831152495
Provider Name (Legal Business Name): FEDERICO CARLOS DE MIRANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 ROGERS AVE SUITE 200
FORT SMITH AR
72903-4165
US

IV. Provider business mailing address

7303 ROGERS AVE SUITE 200
FORT SMITH AR
72903-4165
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-4810
  • Fax: 479-314-2075
Mailing address:
  • Phone: 479-314-4810
  • Fax: 479-314-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC-5393
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: