Provider Demographics
NPI:1184681454
Name:MIRANDA, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name: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 1:4849 N MESA ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5916
Mailing Address - Country:US
Mailing Address - Phone:915-351-6600
Mailing Address - Fax:915-351-6601
Practice Address - Street 1:5849 DIAMOND POINT CIR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-4156
Practice Address - Country:US
Practice Address - Phone:915-351-6600
Practice Address - Fax:915-351-6601
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2295208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020001373OtherRR MEDICARE
TX123715805Medicaid
TX8U9610OtherBCBS & HMO OF TX
NMX2538Medicaid
020001373OtherRR MEDICARE
B24929Medicare UPIN