Provider Demographics
NPI:1003554791
Name:PACKARD, MIRANDA LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:LYNN
Last Name:PACKARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 FAWN DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-2073
Mailing Address - Country:US
Mailing Address - Phone:513-910-7574
Mailing Address - Fax:
Practice Address - Street 1:5854 CINEMA DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1507
Practice Address - Country:US
Practice Address - Phone:513-283-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH007040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist