Provider Demographics
NPI:1457642894
Name:KATHERINE K. MIURA, MD, LLC
Entity Type:Organization
Organization Name:KATHERINE K. MIURA, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:KIMI
Authorized Official - Last Name:MIURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-594-1662
Mailing Address - Street 1:564 LORING AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4276
Mailing Address - Country:US
Mailing Address - Phone:978-594-1662
Mailing Address - Fax:978-336-5887
Practice Address - Street 1:564 LORING AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4276
Practice Address - Country:US
Practice Address - Phone:978-594-1662
Practice Address - Fax:978-336-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA811632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1801853007OtherNPI TYPE 1
MA3156486Medicaid
MA3156486Medicaid