Provider Demographics
NPI:1467783597
Name:DEBARROS, MIA DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:DANIELLE
Last Name:DEBARROS
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 1:9040 JACKSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1000
Mailing Address - Country:US
Mailing Address - Phone:253-968-2200
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-1000
Practice Address - Country:US
Practice Address - Phone:253-968-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60666886208600000X, 208G00000X
NE26423208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2033450Medicaid
NE26423OtherMEDICAL LICENSE
MA278192OtherMEDICAL LICENSE
WA60666886OtherMEDICAL LICENSE