Provider Demographics
NPI:1568746014
Name:LUIS G. MIRANDA, M.D., P.C.
Entity Type:Organization
Organization Name:LUIS G. MIRANDA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-448-1555
Mailing Address - Street 1:11 RALPH PL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4401
Mailing Address - Country:US
Mailing Address - Phone:718-448-1555
Mailing Address - Fax:718-448-3950
Practice Address - Street 1:11 RALPH PL
Practice Address - Street 2:SUITE 202
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4401
Practice Address - Country:US
Practice Address - Phone:718-448-1555
Practice Address - Fax:718-448-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD39081Medicare UPIN