Provider Demographics
NPI:1003090812
Name:IMELDA MIRANDA, M.D.
Entity type:Organization
Organization Name:IMELDA MIRANDA, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-952-8401
Mailing Address - Street 1:PO BOX 2238
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20773-2238
Mailing Address - Country:US
Mailing Address - Phone:301-952-8401
Mailing Address - Fax:301-952-8464
Practice Address - Street 1:7611 S OSBORNE RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4200
Practice Address - Country:US
Practice Address - Phone:301-952-8401
Practice Address - Fax:301-952-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0043276207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01248Medicare PIN
MDF71006Medicare UPIN