Provider Demographics
NPI:1952582223
Name:SAUCEDA, MIRANDA D
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:D
Last Name:SAUCEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 WEST STURDIVANT
Mailing Address - Street 2:PO BOX 137
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-0137
Mailing Address - Country:US
Mailing Address - Phone:573-722-9191
Mailing Address - Fax:573-722-9393
Practice Address - Street 1:502 WEST STURDIVANT
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730-0137
Practice Address - Country:US
Practice Address - Phone:573-722-9191
Practice Address - Fax:573-722-9393
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
268934Medicare Oscar/Certification