Provider Demographics
NPI:1225453376
Name:DE LA CRUZ MIRANDA ORTHOPEDIC SERVICES PSC
Entity Type:Organization
Organization Name:DE LA CRUZ MIRANDA ORTHOPEDIC SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-798-7050
Mailing Address - Street 1:B17 CALLE POPPY
Mailing Address - Street 2:PARQUE FORESTAL
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-798-7050
Mailing Address - Fax:787-787-2107
Practice Address - Street 1:B1 CALLE SANTA CRUZ
Practice Address - Street 2:SUITE 403 CARIMED PLAZA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-798-7050
Practice Address - Fax:787-787-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12964207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR81409OtherTRIPLE S