Basic Information
| Provider Information | |||||||||
| NPI: | 1376075218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIR | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 | ||||||||
| Address2: | DEPT #1536 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352461536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568946701 | ||||||||
| FaxNumber: | 2568403251 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 AL HWY 69 | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359767140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565718000 | ||||||||
| FaxNumber: | 2568403251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DO2146 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.