Provider Demographics
NPI:1821038555
Name:MIRANDA, JOSUE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSUE
Middle Name:A
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 1:5136 PRINCESS ANNE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4228
Mailing Address - Country:US
Mailing Address - Phone:757-473-0003
Mailing Address - Fax:757-497-9510
Practice Address - Street 1:5136 PRINCESS ANNE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4228
Practice Address - Country:US
Practice Address - Phone:757-473-0003
Practice Address - Fax:757-497-9510
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA73-20256Medicaid
VA020000730Medicare ID - Type Unspecified
VAB09645Medicare UPIN