Provider Demographics
NPI:1154703577
Name:ALLEN, MIRANDA (DO)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-5224
Mailing Address - Fax:
Practice Address - Street 1:1009 44TH ST SW STE 101
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4480
Practice Address - Country:US
Practice Address - Phone:616-828-4622
Practice Address - Fax:616-635-2552
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021905208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery