Provider Demographics
NPI:1245499078
Name:MIRANDA, ANTHONY LOREN (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LOREN
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5645
Mailing Address - Country:US
Mailing Address - Phone:530-747-3000
Mailing Address - Fax:
Practice Address - Street 1:239 STONY BROOK CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-4571
Practice Address - Country:US
Practice Address - Phone:209-306-4796
Practice Address - Fax:478-247-8448
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA070199207R00000X
FLTPME1727207R00000X
CAC165064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine