Provider Demographics
NPI:1629216627
Name:MIRAVALLE, AUGUSTO (MD)
Entity Type:Individual
Prefix:MR
First Name:AUGUSTO
Middle Name:
Last Name:MIRAVALLE
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 1:1725 W HARRISON ST STE 309
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3844
Mailing Address - Country:US
Mailing Address - Phone:312-942-8011
Mailing Address - Fax:970-226-6707
Practice Address - Street 1:1725 W HARRISON ST STE 309
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3844
Practice Address - Country:US
Practice Address - Phone:312-942-8011
Practice Address - Fax:970-226-6707
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361182672084N0400X
CO00472462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020217800Medicaid