Provider Demographics
NPI:1275705253
Name:GLANVILLE MIRANDA, CARLOS JAVIER (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JAVIER
Last Name:GLANVILLE MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2790 GODWIN BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8158
Mailing Address - Country:US
Mailing Address - Phone:757-931-4222
Mailing Address - Fax:757-934-4111
Practice Address - Street 1:2790 GODWIN BLVD STE 305
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8158
Practice Address - Country:US
Practice Address - Phone:757-931-4222
Practice Address - Fax:757-934-4111
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-30
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252033208600000X, 208C00000X
PAMT188562208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery