Provider Demographics
NPI:1871740175
Name:COOLE, MIRANDA J (MD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:J
Last Name:COOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:J
Other - Last Name:KEETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-772-8189
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2100022126207Q00000X
KY48172207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK150632Medicare PIN
KYK150635Medicare PIN
KYK150631Medicare PIN
KYK150630Medicare PIN
KYK150633Medicare PIN
KYK150636Medicare PIN
KYK150634Medicare PIN