Provider Demographics
NPI:1164665055
Name:LEVY MIRANDA, SALOMON (MD)
Entity Type:Individual
Prefix:
First Name:SALOMON
Middle Name:
Last Name:LEVY MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9960
Mailing Address - Fax:239-343-9977
Practice Address - Street 1:8380 RIVERWALK PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-343-9960
Practice Address - Fax:239-343-9977
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140310208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102855700Medicaid