Provider Demographics
NPI:1659669877
Name:MIRANDA, CHRISTEL DIZON (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTEL
Middle Name:DIZON
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 PROFESSIONAL DR STE 120
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3779
Practice Address - Country:US
Practice Address - Phone:916-536-2500
Practice Address - Fax:916-780-3904
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47390207Q00000X
CAC158757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine