Provider Demographics
NPI:1477575207
Name:MIRANDA-MORENO, IBELITH (MD)
Entity Type:Individual
Prefix:
First Name:IBELITH
Middle Name:
Last Name:MIRANDA-MORENO
Suffix:
Gender:F
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:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:819 N CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5027
Practice Address - Country:US
Practice Address - Phone:407-288-8242
Practice Address - Fax:407-490-1309
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1390208D00000X, 208D00000X
PR16169261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112495900Medicaid