Provider Demographics
NPI:1639227176
Name:MIRANDA, DIANA E (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:E
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:E
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:328 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2261
Mailing Address - Country:US
Mailing Address - Phone:847-760-6200
Mailing Address - Fax:847-760-6300
Practice Address - Street 1:5255 STATE ROUTE 251
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1005
Practice Address - Country:US
Practice Address - Phone:815-224-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU92371Medicare UPIN
ILU92371Medicare UPIN