Provider Demographics
NPI:1730197807
Name:MIRANDA, RALPH JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:JAMES
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 N EL DORADO ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4467
Mailing Address - Country:US
Mailing Address - Phone:209-473-2020
Mailing Address - Fax:209-473-2176
Practice Address - Street 1:5904 N EL DORADO ST
Practice Address - Street 2:SUITE G
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4467
Practice Address - Country:US
Practice Address - Phone:209-473-2020
Practice Address - Fax:209-473-2176
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7014 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070140Medicaid
SD0070140Medicare ID - Type Unspecified
CASD0070140Medicaid