Healthcare Provider Details

I. General information

NPI: 1043593569
Provider Name (Legal Business Name): MIRIAM ANDRADE STAUB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

IV. Provider business mailing address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-5193
  • Fax:
Mailing address:
  • Phone: 951-683-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME147285
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA53534
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA53534
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0629230
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: