Provider Demographics
NPI:1730834557
Name:MELENDEZ DE MIRANDA, JOSE IGNACIO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:IGNACIO
Last Name:MELENDEZ DE 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:URB. CIUDAD SENORIAL D26 CALLE MAJESTAD
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:939-274-0499
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR34471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080026219195OtherMMM