Provider Demographics
NPI:1578510681
Name:MIRANDA, IMELDA RODRIGUEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:RODRIGUEZ
Last Name:MIRANDA
Suffix:
Gender:F
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:PO BOX 2238
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20773-2238
Mailing Address - Country:US
Mailing Address - Phone:301-952-8401
Mailing Address - Fax:301-952-8464
Practice Address - Street 1:7611 S OSBORNE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4200
Practice Address - Country:US
Practice Address - Phone:301-952-8401
Practice Address - Fax:301-952-8464
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43276207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD137511300Medicaid
MD137511300Medicaid
DC00B903I48Medicare PIN