Provider Demographics
NPI:1598915332
Name:RENFROW, MIRANDA KIRSTIN (DO)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:KIRSTIN
Last Name:RENFROW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 HOSPITAL DR STE 5
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9205
Mailing Address - Country:US
Mailing Address - Phone:802-748-8126
Mailing Address - Fax:802-748-2208
Practice Address - Street 1:1290 HOSPITAL DR STE 5
Practice Address - Street 2:
Practice Address - City:SAINT JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9205
Practice Address - Country:US
Practice Address - Phone:802-748-8126
Practice Address - Fax:802-748-2208
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4949207W00000X
VT032-0129313207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200307490AMedicaid
OKOKA102503OtherPTAN MEDICARE
OK1598915332Medicare PIN