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General NPI Number Information
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NPI Number | 1053765545
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Entity Type | Organization
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Legal Business Name | MIRANDA MEDICAL, PLLC
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Dates
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Enumeration Date | 04/20/2016
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Last Update Date | 04/20/2016
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Provider Practice Location Address
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Address Line | 706 N COLLEGE RD SUITE A
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City | TWIN FALLS
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State | ID
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Zip | 83301-5824
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Country | US
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Telephone | 208-736-8006
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Fax | 208-329-7159
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Provider Business Mailing Address
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Address Line | PO BOX 5498
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City | TWIN FALLS
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State | ID
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Zip | 83303-5498
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Country | US
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Telephone | 208-736-8006
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Fax | 208-329-7159
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Authorized Official
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Title or Position | CEO
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Name | DR. A RICHARD MIRANDA
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Credential | M.D.
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Telephone | 208-420-1319
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | MD151354
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | M-9799
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License Number State | ID
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