Provider Demographics
NPI:1942402334
Name:DE JESUS MIRANDA, LUIS A (DO)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:DE JESUS MIRANDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE JOSE DE DIEGO #30
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739
Mailing Address - Country:US
Mailing Address - Phone:787-714-4550
Mailing Address - Fax:787-714-4550
Practice Address - Street 1:CALLE JOSE DE DIEGO #30
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739
Practice Address - Country:US
Practice Address - Phone:787-714-4550
Practice Address - Fax:787-714-4550
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist