Basic Information
| Provider Information | |||||||||
| NPI: | 1770504664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHEILA L MIRANDA MD PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9811 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 2543 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
| FaxNumber: | 7022563307 | ||||||||
| Practice Location | |||||||||
| Address1: | 9811 W CHARLESTON BLVD | ||||||||
| Address2: | 2543 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029490885 | ||||||||
| FaxNumber: | 7029517579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | MIRANDA | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7029490885 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11089 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1770504664 | 01 | GROUP NPI | OTHER | 1770504664 | 01 | NV | NPI GROUP | OTHER | 100504137 | 05 | NV | MEDICAID |