Healthcare Provider Details

I. General information

NPI: 1891798633
Provider Name (Legal Business Name): ROBERTO MIRANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 DESSAU RIDGE LN APT 602 STE B
AUSTIN TX
78754-2121
US

IV. Provider business mailing address

1508 DESSAU RIDGE LN APT 602 STE B
AUSTIN TX
78754-2121
US

V. Phone/Fax

Practice location:
  • Phone: 512-477-9202
  • Fax: 512-472-9473
Mailing address:
  • Phone: 512-477-9202
  • Fax: 512-472-9473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE2740
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: