Provider Demographics
NPI:1972751097
Name:MIRANDA, DION GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:DION
Middle Name:GREGORY
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:636-441-0067
Mailing Address - Fax:636-441-1062
Practice Address - Street 1:4800 MEXICO RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-441-0067
Practice Address - Fax:636-441-1062
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2008020488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
124510010Medicare PIN