Provider Demographics
NPI:1437112000
Name:MIRANDA, CHARLES HENRY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
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 1:10103 RIDGE GATE PKWY
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124
Mailing Address - Country:US
Mailing Address - Phone:303-799-8890
Mailing Address - Fax:303-799-8891
Practice Address - Street 1:10103 RIDGE GATE PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:303-799-8890
Practice Address - Fax:303-799-8891
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33478207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89530063Medicaid
C506888Medicare PIN
CO89530063Medicaid