Provider Demographics
NPI:1366016065
Name:SMITH, MIRANDA OLIVIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:OLIVIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:217-224-9484
Mailing Address - Fax:217-224-7950
Practice Address - Street 1:612 N 11TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2662
Practice Address - Country:US
Practice Address - Phone:217-224-9484
Practice Address - Fax:217-224-7950
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125077938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine