Provider Demographics
NPI:1699738195
Name:MIRANDA, MICHAEL S (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MIRANDA
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 1:128 DANIEL AVE
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927
Mailing Address - Country:US
Mailing Address - Phone:479-675-2455
Mailing Address - Fax:479-675-4940
Practice Address - Street 1:128 DANIEL AVE
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927
Practice Address - Country:US
Practice Address - Phone:479-675-2455
Practice Address - Fax:479-675-4940
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135455001Medicaid
ARG80516Medicare UPIN
AR135455001Medicaid