Provider Demographics
NPI:1518999259
Name:MIRANDE, RAUL A (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:A
Last Name:MIRANDE
Suffix:
Gender:M
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:PO BOX 5109
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-0119
Mailing Address - Country:US
Mailing Address - Phone:541-882-1540
Mailing Address - Fax:541-882-2583
Practice Address - Street 1:2664 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1105
Practice Address - Country:US
Practice Address - Phone:541-880-2881
Practice Address - Fax:541-883-2250
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19229208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020027915OtherRAILROAD MEDICARE
OR073143Medicaid
020027915OtherRAILROAD MEDICARE
ORG02756Medicare UPIN