Provider Demographics
NPI:1659447514
Name:MIRANADA GALLOZA, MIRELIS
Entity Type:Individual
Prefix:
First Name:MIRELIS
Middle Name:
Last Name:MIRANADA GALLOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 3 BOX 31531
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9757
Mailing Address - Country:US
Mailing Address - Phone:787-238-2923
Mailing Address - Fax:
Practice Address - Street 1:550 CALLE CONCEPCION VERA AYALA
Practice Address - Street 2:HOSPITAL SAN CARLOS BORROMEO
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-0068
Practice Address - Country:US
Practice Address - Phone:787-877-8000
Practice Address - Fax:787-551-7066
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16589207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRGR305AMedicare UPIN