Provider Demographics
NPI:1972536597
Name:MIRANDA, MARY ANN V (MD)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:V
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:303 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-5246
Mailing Address - Country:US
Mailing Address - Phone:512-732-2774
Mailing Address - Fax:512-344-9221
Practice Address - Street 1:2025 MEMORY LN STE 400A
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-7488
Practice Address - Country:US
Practice Address - Phone:254-435-4995
Practice Address - Fax:254-432-5952
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK25323207R00000X
TXN5247207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200098480AMedicaid
OK200098480AMedicaid
I59984Medicare UPIN