Provider Demographics
NPI:1639474216
Name:SMITH, MIRANDA BOONE (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:BOONE
Last Name:SMITH
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 1:801 MERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-4748
Mailing Address - Country:US
Mailing Address - Phone:516-393-8941
Mailing Address - Fax:
Practice Address - Street 1:801 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-4748
Practice Address - Country:US
Practice Address - Phone:516-393-8941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278947-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation