Healthcare Provider Details

I. General information

NPI: 1972536597
Provider Name (Legal Business Name): MARY ANN V MIRANDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/15/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 MEMORY LN STE 400A
HARKER HEIGHTS TX
76548-7488
US

IV. Provider business mailing address

303 W MAIN ST
ROUND ROCK TX
78664-5246
US

V. Phone/Fax

Practice location:
  • Phone: 254-435-4995
  • Fax: 254-432-5952
Mailing address:
  • Phone: 512-732-2774
  • Fax: 512-344-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25323
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberN5247
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: