Provider Demographics
NPI:1750963617
Name:MIRANDA, LUIS EMILIO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EMILIO
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SANSOM ST STE 1615B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5002
Mailing Address - Country:US
Mailing Address - Phone:215-955-2363
Mailing Address - Fax:215-955-8600
Practice Address - Street 1:1020 SANSOM ST STE 1615B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5002
Practice Address - Country:US
Practice Address - Phone:215-955-2363
Practice Address - Fax:215-955-8600
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program