Provider Demographics
NPI:1871226324
Name:MIRANDA, PATRICK JAMES (OD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JAMES
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43309 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-6221
Mailing Address - Country:US
Mailing Address - Phone:727-938-2020
Mailing Address - Fax:727-938-5606
Practice Address - Street 1:1050 OLD CAMP RD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-1762
Practice Address - Country:US
Practice Address - Phone:352-350-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115197100Medicaid