Provider Demographics
NPI:1104845080
Name:MIRANDA, DIEGO A (MD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:A
Last Name: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 1:2449 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-212-7841
Mailing Address - Fax:318-212-7768
Practice Address - Street 1:2449 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 340
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-212-7841
Practice Address - Fax:318-212-7768
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA199959207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478997Medicaid
LA4J433C616Medicare ID - Type Unspecified
LA1478997Medicaid
LA4J433CX02Medicare PIN