Provider Demographics
NPI:1376630202
Name:DE JESUS MIRANDA, JORGE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:R
Last Name:DE JESUS MIRANDA
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12 CALLE 1
Mailing Address - Street 2:EXT. ALTURAS DE SAN PATRICIO
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-3128
Mailing Address - Country:US
Mailing Address - Phone:787-754-9586
Mailing Address - Fax:787-754-9589
Practice Address - Street 1:572 CALLE DE DIEGO
Practice Address - Street 2:SABANA LLANA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3815
Practice Address - Country:US
Practice Address - Phone:787-754-9586
Practice Address - Fax:787-754-9589
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR6045207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR97545Medicare ID - Type Unspecified
PRE67411Medicare UPIN