Individual
MARIO MIRANDA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
221 NE GLEN OAK AVE, PEORIA, IL 61603-4307
(309) 672-5522
Mailing address
21276 NETWORK PL, CHICAGO, IL 60673-1212
(877) 485-4474
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
—
IL
207Q00000X
Family Medicine Physician
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
36096715
BCBS
IL
01
—
P00196855
RAILROAD MEDICARE
IL
Enumeration date
04/04/2006
Last updated
02/05/2008
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