Healthcare Provider Details

I. General information

NPI: 1306896303
Provider Name (Legal Business Name): CARRIE JOY MIRANDA O. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 WILLOW CREEK RD
PRESCOTT AZ
86301-1108
US

IV. Provider business mailing address

3120 MONTANA DR
PRESCOTT AZ
86301-4626
US

V. Phone/Fax

Practice location:
  • Phone: 928-778-3950
  • Fax: 928-778-3999
Mailing address:
  • Phone: 928-778-2274
  • Fax: 928-778-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0844
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: