Provider Demographics
NPI:1568441244
Name:MIRANDA, ALTAGRACIA (MD)
Entity Type:Individual
Prefix:
First Name:ALTAGRACIA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:MIRANDA-BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 5TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-6510
Mailing Address - Country:US
Mailing Address - Phone:305-305-0310
Mailing Address - Fax:
Practice Address - Street 1:1000 5TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-6510
Practice Address - Country:US
Practice Address - Phone:305-305-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87277207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267920500Medicaid
FL29238OtherBCBS
FL267920500Medicaid
FL29238OtherBCBS
H42866Medicare UPIN