Provider Demographics
NPI:1063557759
Name:MIRALLES, ROYLE (MD)
Entity type:Individual
Prefix:
First Name:ROYLE
Middle Name:
Last Name:MIRALLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:
Mailing Address - City:CYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:315-946-7066
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:WAYNE BEHAVIORAL HEALTH NETWORK
Practice Address - City:CYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-7066
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12659412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060 00126594Medicaid
CC2470Medicare ID - Type Unspecified