Provider Demographics
NPI:1891798633
Name:MIRANDA, ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 DESSAU RIDGE LN APT 602
Mailing Address - Street 2:STE B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-2121
Mailing Address - Country:US
Mailing Address - Phone:512-477-9202
Mailing Address - Fax:512-472-9473
Practice Address - Street 1:1508 DESSAU RIDGE LN APT 602
Practice Address - Street 2:STE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-2121
Practice Address - Country:US
Practice Address - Phone:512-477-9202
Practice Address - Fax:512-472-9473
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00318QOtherBCBS
TX140282837Medicaid
TX140282837Medicaid