Provider Demographics
NPI:1376075218
Name:MIR, JACQUELINE DANIELLE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DANIELLE
Last Name:MIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT #1536
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-1536
Mailing Address - Country:US
Mailing Address - Phone:256-894-6701
Mailing Address - Fax:256-840-3251
Practice Address - Street 1:8000 AL HWY 69
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-7140
Practice Address - Country:US
Practice Address - Phone:256-571-8000
Practice Address - Fax:256-840-3251
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO2146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine