=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669565669
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | A. RICHARD MIRANDA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 706 N COLLEGE RD SUITE A
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-8006
-----------------------------------------------------
Fax | 208-329-7159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5498
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83303-5498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-8001
-----------------------------------------------------
Fax | 208-329-7159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | MD151354
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | M-9799
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------