Provider Demographics
NPI:1093892366
Name:MIRANDA, DAVID AARON (MPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:AARON
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 N. BLACK CANYON HWY
Mailing Address - Street 2:#100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2200
Mailing Address - Country:US
Mailing Address - Phone:602-249-0607
Mailing Address - Fax:602-249-0741
Practice Address - Street 1:5815 N. BLACK CANYON HWY
Practice Address - Street 2:#100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2200
Practice Address - Country:US
Practice Address - Phone:602-249-0607
Practice Address - Fax:602-249-0741
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0461220OtherBCBS
AZZ74658Medicare PIN