Provider Demographics
NPI:1184670333
Name:FERNANDEZ MIRO, ULISES D (MD)
Entity Type:Individual
Prefix:
First Name:ULISES
Middle Name:D
Last Name:FERNANDEZ MIRO
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 1:1149 SAN MICHELE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-6704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1874 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5545
Practice Address - Country:US
Practice Address - Phone:772-337-7676
Practice Address - Fax:772-337-9034
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076116207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43618OtherBCBS FLORIDA
FL254498900Medicaid
FL050088996OtherRR MEDICARE
FL43816XMedicare PIN
FL050088996OtherRR MEDICARE
FL43816YMedicare PIN