Provider Demographics
NPI:1609944131
Name:MIRANDA, NANCY ABIGAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:ABIGAIL
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2428
Mailing Address - Country:US
Mailing Address - Phone:312-413-1789
Mailing Address - Fax:312-413-7812
Practice Address - Street 1:4636 S BISHOP ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3240
Practice Address - Country:US
Practice Address - Phone:773-523-2615
Practice Address - Fax:773-523-8599
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine