Provider Demographics
NPI:1437198215
Name:MIRANDA, MATILDA
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22581
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-2581
Mailing Address - Country:US
Mailing Address - Phone:610-482-4795
Mailing Address - Fax:856-528-3117
Practice Address - Street 1:215 UNION AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3063
Practice Address - Country:US
Practice Address - Phone:908-722-2900
Practice Address - Fax:908-722-1856
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07737000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0062235Medicaid
NJ25MA07737000OtherNJ MEDICAL LICENSE
NJD08538800OtherCONTROLLED DANGERAOUS SUB
NJD08538800OtherCONTROLLED DANGERAOUS SUB
NJ25MA07737000OtherNJ MEDICAL LICENSE
BM8912001OtherFEDERAL DEA