Provider Demographics
NPI:1972525327
Name:ANTONIO-MIRANDA, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ANTONIO-MIRANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 KINGSLEY AVENUE
Mailing Address - Street 2:BLDG 3B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4491
Mailing Address - Country:US
Mailing Address - Phone:904-269-9200
Mailing Address - Fax:904-269-7796
Practice Address - Street 1:1409 KINGSLEY AVENUE
Practice Address - Street 2:BLDG 3B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4491
Practice Address - Country:US
Practice Address - Phone:904-269-9200
Practice Address - Fax:904-269-7796
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74317207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255678200Medicaid
FLE0276ZMedicare ID - Type Unspecified
FL255678200Medicaid