Provider Demographics
NPI:1659684231
Name:REED, MIRANDA L (DO)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:REED
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:73 PRESTIGE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6370
Mailing Address - Country:US
Mailing Address - Phone:770-800-3455
Mailing Address - Fax:770-284-8380
Practice Address - Street 1:105 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2381
Practice Address - Country:US
Practice Address - Phone:770-800-3455
Practice Address - Fax:770-284-8380
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA77116207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003186501AMedicaid