Provider Demographics
NPI:1376879031
Name:MIRANDA, CARLOS GUILLERMO (MD)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:GUILLERMO
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 1:10051 5TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2211
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:813-514-8891
Practice Address - Street 1:2301 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4124
Practice Address - Country:US
Practice Address - Phone:407-891-7244
Practice Address - Fax:407-891-5741
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08679200207R00000X
FLME105965207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002521000Medicaid
12076391OtherCAQH
FL002521000Medicaid