Provider Demographics
NPI:1851415541
Name:DE MIRANDA, EDWARD GARCIA (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GARCIA
Last Name:DE 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 1:4800 BELFORT ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-483-5850
Mailing Address - Fax:904-483-5860
Practice Address - Street 1:4800 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6004
Practice Address - Country:US
Practice Address - Phone:904-265-4801
Practice Address - Fax:904-265-4811
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME005001207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280222800Medicaid
GA125776975AMedicaid
FL2802228-00Medicaid
FL2802228-00Medicaid
FL280222800Medicaid
16763Medicare UPIN
FL16763XMedicare PIN
FL16763YMedicare ID - Type Unspecified
FL16763WMedicare PIN