Provider Demographics
NPI:1568499358
Name:MIRANDA, JOSEPH R (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:MIRANDA
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 645
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0645
Mailing Address - Country:US
Mailing Address - Phone:316-689-5050
Mailing Address - Fax:316-689-6192
Practice Address - Street 1:3600 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3713
Practice Address - Country:US
Practice Address - Phone:316-689-5050
Practice Address - Fax:316-689-6192
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS222402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS018205OtherBCBS
KS100141070CMedicaid
KS200136OtherHPK
KS1209OtherPHS
KS12149471OtherMULTIPLAN
KS16908OtherCOVENTRY
KS12149471OtherMULTIPLAN
D17410Medicare UPIN