Provider Demographics
NPI:1275739427
Name:WORSTER, MIRANDA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:LYNN
Last Name:WORSTER
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:298 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9443
Practice Address - Country:US
Practice Address - Phone:864-885-7758
Practice Address - Fax:864-885-7749
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301097Medicaid
SCAA57917951Medicare PIN