Provider Demographics
NPI:1558365882
Name:MIRA, ALLAN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:JOSEPH
Last Name:MIRA
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 1:1312 BOSLER PL
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4284
Mailing Address - Country:US
Mailing Address - Phone:717-243-6904
Mailing Address - Fax:
Practice Address - Street 1:1312 BOSLER PL
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-4284
Practice Address - Country:US
Practice Address - Phone:717-243-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2020-11-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
PAMD014478E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA69186Medicare PIN
PAC28889Medicare UPIN