Provider Demographics
NPI:1093782963
Name:DIAZ MIRANDA, CONSTANTINO (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANTINO
Middle Name:
Last Name:DIAZ 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:PO BOX 30707
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-0707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 2ND STREET
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3703
Practice Address - Country:US
Practice Address - Phone:423-625-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN021298207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10393I0188Medicare PIN
TNF13144Medicare UPIN