Provider Demographics
NPI:1871569921
Name:MIRANDA, ROBERTO N (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:N
Last Name: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:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2740207ZP0102X
MO114313207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191592801 (MDACC)Medicaid
TX8AL252OtherBCBS (MDACC)
MO209682608Medicaid
TXP00452927OtherRR MEDICARE (MDACC)
TX191592801 (MDACC)Medicaid
TX8K1897 (MDACC)Medicare PIN
MOG63561Medicare UPIN