Provider Demographics
NPI:1902131048
Name:MIRANDA, KRISTEN ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANGELA
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:415-206-8610
Mailing Address - Fax:
Practice Address - Street 1:1515 FRUITVALE AVENUE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2322
Practice Address - Country:US
Practice Address - Phone:510-535-6300
Practice Address - Fax:510-535-4019
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING207Q00000X
CAA110321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine