Provider Demographics
NPI:1932197712
Name:MIRAFLORES, KATHLEEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:MIRAFLORES
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 1:451 SPRINGS END LN NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-3076
Mailing Address - Country:US
Mailing Address - Phone:678-926-1545
Mailing Address - Fax:
Practice Address - Street 1:6995 CONCOURSE PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4551
Practice Address - Country:US
Practice Address - Phone:770-489-2622
Practice Address - Fax:770-489-8318
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2030152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5943371428Medicaid