Provider Demographics
NPI:1831125798
Name:MIRANDA, MICHELE R (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:R
Last Name:MIRANDA
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 1:421 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9764
Mailing Address - Country:US
Mailing Address - Phone:413-584-4040
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002099OtherCONNECTICARE
CT090002099CT02OtherANTHEM BLUE CROSS
CT004224721Medicaid
CT2V2740OtherHEALTHNET
CT4111728OtherAETNA
CTP2679716OtherOXFORD
CTCT2099OtherCOLE VISION
CTT59401Medicare UPIN
CT004224721Medicaid