Provider Demographics
NPI:1457598690
Name:ROBERTO MIRANDA, MD PA
Entity Type:Organization
Organization Name:ROBERTO MIRANDA, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-477-9202
Mailing Address - Street 1:110 CHALMERS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4489
Mailing Address - Country:US
Mailing Address - Phone:512-477-9202
Mailing Address - Fax:512-472-9473
Practice Address - Street 1:110 CHALMERS AVE STE B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4489
Practice Address - Country:US
Practice Address - Phone:512-477-9202
Practice Address - Fax:512-472-9473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00318QMedicare UPIN