Healthcare Provider Details

I. General information

NPI: 1508264193
Provider Name (Legal Business Name): WHITNEY ROBERSON MIRANDA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2014
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 E IRLO BRONSON MEMORIAL HWY
KISSIMMEE FL
34744-5401
US

IV. Provider business mailing address

PO BOX 207151
DALLAS TX
75320-7151
US

V. Phone/Fax

Practice location:
  • Phone: 407-847-0057
  • Fax: 407-518-0003
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5014
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC005014
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC005014
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC005014
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC005014
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: