Provider Demographics
NPI:1225376726
Name:MIRANDA ROSA, MILTON R (MD)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:R
Last Name:MIRANDA ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:135 CHAMPIONS BND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4804
Mailing Address - Country:US
Mailing Address - Phone:787-925-5756
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:787-925-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18615208000000X
TXS7729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics