Provider Demographics
NPI:1144551227
Name:MIRANDA, MANUEL ANTONIO
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:ANTONIO
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:MISS
Other - First Name:MORAIMA
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:E75 VILLA ORIENTE
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-3444
Mailing Address - Country:US
Mailing Address - Phone:787-556-0709
Mailing Address - Fax:
Practice Address - Street 1:E75 VILLA ORIENTE
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3444
Practice Address - Country:US
Practice Address - Phone:787-556-0709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
PR1802671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR66-0740736OtherEIN