1366537201 NPI number — EGBERT MIRANDA MDPA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366537201 NPI number — EGBERT MIRANDA MDPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EGBERT MIRANDA MDPA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366537201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5866 S STAPLES ST
Provider Second Line Business Mailing Address:
STE. 403
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78413-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-991-5520
Provider Business Mailing Address Fax Number:
361-991-5521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5866 S STAPLES ST
Provider Second Line Business Practice Location Address:
STE. 403
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78413-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-991-5520
Provider Business Practice Location Address Fax Number:
361-991-5521
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIRANDA
Authorized Official First Name:
EGBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
361-991-5520

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00F33D . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 153788-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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