Provider Demographics
NPI:1255044483
Name:MIRANDA, DAVID JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 HOMEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2804
Mailing Address - Country:US
Mailing Address - Phone:410-255-1680
Mailing Address - Fax:
Practice Address - Street 1:202 HOMEWOOD TER
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2804
Practice Address - Country:US
Practice Address - Phone:410-255-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02969103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical