Provider Demographics
NPI:1104815117
Name:AGOSTINI-MIRANDA, ALEX ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:ALEXANDER
Last Name:AGOSTINI-MIRANDA
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:A
Other - Last Name:AGOSTINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2101 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2417
Mailing Address - Country:US
Mailing Address - Phone:701-232-3241
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA43934207P00000X, 207Q00000X
MN76009207P00000X, 207Q00000X
ARE-7802207P00000X
TNMD0000039280207P00000X, 207Q00000X
ALMD.30950207P00000X, 207Q00000X
KY44351207P00000X, 207Q00000X
ND20002207P00000X, 207Q00000X
FLME95555207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275224700Medicaid
PRI-11807Medicare UPIN
FLU8069SMedicare UPIN
FL275224700Medicaid