Provider Demographics
NPI:1568902013
Name:MIRANDA, JORDAN L
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SYLVAMDUR AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4015
Mailing Address - Country:US
Mailing Address - Phone:201-562-6634
Mailing Address - Fax:
Practice Address - Street 1:51 SYLVAMDUR AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4015
Practice Address - Country:US
Practice Address - Phone:201-562-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program