Provider Demographics
NPI:1568061372
Name:MIRANDA, ELIEL (MD)
Entity Type:Individual
Prefix:
First Name:ELIEL
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:HC 3 BOX 31531
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9757
Mailing Address - Country:US
Mailing Address - Phone:787-214-2067
Mailing Address - Fax:
Practice Address - Street 1:CARR 416 KM 1.3
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602
Practice Address - Country:US
Practice Address - Phone:787-214-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22064208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080010193161Medicaid