Provider Demographics
NPI:1639264096
Name:MIRANDA, DAVID V (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:V
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 S BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4642
Mailing Address - Country:US
Mailing Address - Phone:225-644-0290
Mailing Address - Fax:225-644-4201
Practice Address - Street 1:2251 S BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4642
Practice Address - Country:US
Practice Address - Phone:225-644-0290
Practice Address - Fax:225-644-4201
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B743Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL ID
LA4B743C492Medicare ID - Type UnspecifiedMEDICARE PERSONAL/GROUP
LA4B743CD04Medicare ID - Type UnspecifiedMEDICARE PERSONAL/GROUP