Provider Demographics
NPI:1396449070
Name:MIRACOLA, JOHNNY (DO)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:MIRACOLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6715
Mailing Address - Country:US
Mailing Address - Phone:954-987-2421
Mailing Address - Fax:954-987-1398
Practice Address - Street 1:255 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6715
Practice Address - Country:US
Practice Address - Phone:954-987-2421
Practice Address - Fax:954-987-1398
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6492156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician