Provider Demographics
NPI:1073554168
Name:MIRANDA, CONRAD J R IV (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:J R
Last Name:MIRANDA
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:9900 BALBOA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5403
Mailing Address - Country:US
Mailing Address - Phone:818-701-0017
Mailing Address - Fax:818-701-0073
Practice Address - Street 1:9900 BALBOA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5403
Practice Address - Country:US
Practice Address - Phone:818-701-0017
Practice Address - Fax:818-701-0073
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CAC51139208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC51139OtherPHYSICIAN CA LICENSE
CAE00425Medicare UPIN