Provider Demographics
NPI:1497797112
Name:MIRANDA, RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
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 1:7025 N MAPLE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8006
Mailing Address - Country:US
Mailing Address - Phone:559-431-6600
Mailing Address - Fax:559-431-6106
Practice Address - Street 1:7025 N MAPLE AVE STE 108
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8006
Practice Address - Country:US
Practice Address - Phone:559-431-6600
Practice Address - Fax:559-431-6106
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG66119OtherBLUE CROSS
CAG66119Medicaid