Provider Demographics
NPI:1689327272
Name:MIRANDA OH, INJA
Entity Type:Individual
Prefix:
First Name:INJA
Middle Name:
Last Name:MIRANDA OH
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 1:6502 LOTUS ST
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-0778
Mailing Address - Country:US
Mailing Address - Phone:831-220-2163
Mailing Address - Fax:
Practice Address - Street 1:6502 LOTUS ST
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-0778
Practice Address - Country:US
Practice Address - Phone:831-220-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42612261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7537113OtherDRIVE LICENSE