Provider Demographics
NPI:1497990048
Name:MAYNARD, MIRANDA WOOD (OD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:WOOD
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-2811
Mailing Address - Country:US
Mailing Address - Phone:662-489-5907
Mailing Address - Fax:
Practice Address - Street 1:26 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2811
Practice Address - Country:US
Practice Address - Phone:662-489-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I413401OtherMEDICARE INDIVIDUAL PTAN
MS0652140001OtherCIGNA GOVERNMENT
MS09834040Medicaid