Provider Demographics
NPI:1629365820
Name:EGBERT MIRANDA M.D. P.A.
Entity Type:Organization
Organization Name:EGBERT MIRANDA M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EGBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-991-5520
Mailing Address - Street 1:5934 S STAPLES ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3842
Mailing Address - Country:US
Mailing Address - Phone:361-991-5520
Mailing Address - Fax:361-991-5521
Practice Address - Street 1:5934 S STAPLES ST STE 205
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3842
Practice Address - Country:US
Practice Address - Phone:361-991-5520
Practice Address - Fax:361-991-5521
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EGBERT MIRANDA M.D. P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-08
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7792207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1093785230OtherTPI# 153378801