Provider Demographics
NPI:1679507107
Name:MIRANDA, RAY CESPEDES (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:CESPEDES
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57-18 WOODSIDE AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57-18 WOODSIDE AVE
Practice Address - Street 2:2ND FL
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-672-7702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217149207R00000X
LA325336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
848211Medicare PIN
NY848211Medicare PIN
H13522Medicare UPIN