Provider Demographics
NPI:1083059711
Name:MUNDAY, MIRANDA LOU (MD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOU
Last Name:MUNDAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2091
Mailing Address - Country:US
Mailing Address - Phone:859-236-1080
Mailing Address - Fax:
Practice Address - Street 1:303 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2091
Practice Address - Country:US
Practice Address - Phone:859-236-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3333208000000X
KY48854208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100307540Medicaid