Provider Demographics
NPI:1831152495
Name:DE MIRANDA, FEDERICO CARLOS (MD)
Entity type:Individual
Prefix:
First Name:FEDERICO
Middle Name:CARLOS
Last Name:DE MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 ROGERS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4165
Mailing Address - Country:US
Mailing Address - Phone:479-314-4810
Mailing Address - Fax:479-314-2075
Practice Address - Street 1:7303 ROGERS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4165
Practice Address - Country:US
Practice Address - Phone:479-314-4810
Practice Address - Fax:479-314-2075
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5393208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150597002Medicaid
ARF31893OtherBCBS CORP #
AR105837001Medicaid
AR5-1332OtherBCBS IND. #
F 31893Medicare UPIN