Provider Demographics
NPI:1164451910
Name:FERNANDO G MIRANDA MD
Entity Type:Organization
Organization Name:FERNANDO G MIRANDA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:G
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-231-1155
Mailing Address - Street 1:2801 OCEAN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2025
Mailing Address - Country:US
Mailing Address - Phone:772-231-1155
Mailing Address - Fax:772-231-1155
Practice Address - Street 1:2801 OCEAN DR STE 202
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-2025
Practice Address - Country:US
Practice Address - Phone:772-231-1155
Practice Address - Fax:772-231-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA26188Medicare UPIN
FL31169Medicare ID - Type Unspecified