Healthcare Provider Details

I. General information

NPI: 1528029360
Provider Name (Legal Business Name): ESTELA MIQUIABAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S SHOOP AVE
WAUSEON OH
43567-1702
US

IV. Provider business mailing address

5620 SOUTHWYCK BLVD
TOLEDO OH
43614-1501
US

V. Phone/Fax

Practice location:
  • Phone: 419-335-2015
  • Fax:
Mailing address:
  • Phone: 419-335-2015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35061019K
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: