Provider Demographics
NPI:1275604043
Name:MIRANDA, RENE E (MD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:E
Last Name:MIRANDA
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 1:422 E MABEL ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-7457
Mailing Address - Country:US
Mailing Address - Phone:520-979-6849
Mailing Address - Fax:
Practice Address - Street 1:422 E MABEL ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-7457
Practice Address - Country:US
Practice Address - Phone:520-979-6849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34586207N00000X
ORMD272298207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E97606Medicare UPIN