Provider Demographics
NPI:1003858762
Name:GOODALE, MIRANDA ANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:ANNE
Last Name:GOODALE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-7400
Mailing Address - Country:US
Mailing Address - Phone:812-448-9290
Mailing Address - Fax:812-448-9296
Practice Address - Street 1:955 W CRAIG AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-7400
Practice Address - Country:US
Practice Address - Phone:812-448-9290
Practice Address - Fax:812-448-9296
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001015A213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200825350AMedicaid
0385202OtherCIGNA
5692086OtherFIRSTHEALTH
IN000000392910OtherBLUE CROSS BLUE SHIELD
0732240001OtherDMERC WITH PPG
IN37278OtherIHN PPO NETWORK
IN200825350AMedicaid
IN5725740001Medicare NSC
IN000000392910OtherBLUE CROSS BLUE SHIELD
5692086OtherFIRSTHEALTH
0385202OtherCIGNA