Provider Demographics
NPI:1548239213
Name:MIRANDA, LUIS DA GRACA (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:DA GRACA
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11 RALPH PLACE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304
Mailing Address - Country:US
Mailing Address - Phone:718-448-1555
Mailing Address - Fax:718-448-3950
Practice Address - Street 1:11 RALPH PLACE
Practice Address - Street 2:SUITE 202
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:718-448-1555
Practice Address - Fax:718-448-3950
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY115278208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00251487Medicaid
D39081Medicare UPIN
NY00251487Medicaid