Provider Demographics
NPI:1003250630
Name:MIRANDA, OMAR ALEXIS (LND)
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:ALEXIS
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STREET 1 B-12
Mailing Address - Street 2:URB. COLINAS VERDES
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:787-752-3928
Mailing Address - Fax:
Practice Address - Street 1:STREET 1 B-12
Practice Address - Street 2:URB. COLINAS VERDES
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-5311
Practice Address - Country:US
Practice Address - Phone:787-752-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1843133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid
PR$$$$$$$$$Medicaid