Provider Demographics
NPI:1720561483
Name:MIRANDA, JOANNA (OD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1308
Mailing Address - Country:US
Mailing Address - Phone:909-625-6567
Mailing Address - Fax:
Practice Address - Street 1:5237 ARROW HWY
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1308
Practice Address - Country:US
Practice Address - Phone:909-625-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34026152W00000X
CA34026TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist