Provider Demographics
NPI:1336178706
Name:MIRANDA, RAFAEL ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANGEL
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 1:4692 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3410
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1117
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1117
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC143U9OtherBCBS
P00367203OtherRAILROAD MEDICARE
192202OtherMEDCOST
7139831OtherAETNA
NC5905104Medicaid
2058632Medicare PIN
192202OtherMEDCOST
P00367203Medicare PIN