Provider Demographics
NPI:1184234825
Name:MIRANDA, LIDIORE JOHN A
Entity type:Individual
Prefix:
First Name:LIDIORE JOHN
Middle Name:A
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 STATON ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2583
Mailing Address - Country:US
Mailing Address - Phone:407-236-3287
Mailing Address - Fax:
Practice Address - Street 1:610 E HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-4830
Practice Address - Country:US
Practice Address - Phone:432-837-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1291732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist