Provider Demographics
NPI:1801853007
Name:MIURA, KATHERINE KIMI (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KIMI
Last Name:MIURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CTR
Mailing Address - Street 2:SUITE 423-G
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6115
Mailing Address - Country:US
Mailing Address - Phone:978-594-1662
Mailing Address - Fax:978-336-5887
Practice Address - Street 1:100 CUMMINGS CTR
Practice Address - Street 2:SUITE 423-G
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6115
Practice Address - Country:US
Practice Address - Phone:978-594-1662
Practice Address - Fax:978-336-5887
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA811632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1457642894OtherNPI TYPE 2
MA1801853007OtherNPI TYPE 1
MA3156486Medicaid
MA1457642894OtherNPI TYPE 2