Provider Demographics
NPI:1720216377
Name:JOSE MIRANDA MD INC.
Entity Type:Organization
Organization Name:JOSE MIRANDA MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-939-7500
Mailing Address - Street 1:PO BOX 571470
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-1470
Mailing Address - Country:US
Mailing Address - Phone:310-388-9012
Mailing Address - Fax:310-388-9013
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:#301
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1901
Practice Address - Country:US
Practice Address - Phone:714-939-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA478531Medicare PIN