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General NPI Number Information
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NPI Number | 1831152495
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Entity Type | Individual
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Provider Name | FEDERICO CARLOS DE MIRANDA M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 02/13/2014
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Provider Practice Location Address
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Address Line | 7303 ROGERS AVE SUITE 200
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City | FORT SMITH
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State | AR
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Zip | 72903-4165
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Country | US
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Telephone | 479-314-4810
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Fax | 479-314-2075
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Provider Business Mailing Address
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Address Line | 7303 ROGERS AVE SUITE 200
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City | FORT SMITH
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State | AR
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Zip | 72903-4165
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Country | US
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Telephone | 479-314-4810
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Fax | 479-314-2075
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | C-5393
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License Number State | AR
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