Provider Demographics
NPI:1770622169
Name:MIRANDA MARTIR, ANSELMO (MD)
Entity type:Individual
Prefix:
First Name:ANSELMO
Middle Name:
Last Name:MIRANDA MARTIR
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 1:66 CALLE SANTA CRUZ
Mailing Address - Street 2:SUITE 408 INSTITUTO SAN PABLO
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7041
Mailing Address - Country:US
Mailing Address - Phone:787-740-6450
Mailing Address - Fax:787-780-9059
Practice Address - Street 1:66 CALLE SANTA CRUZ
Practice Address - Street 2:SUITE 408 INSTITUTO SAN PABLO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7041
Practice Address - Country:US
Practice Address - Phone:787-740-6450
Practice Address - Fax:787-780-9059
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2-8724Medicare ID - Type Unspecified
PRE-31515Medicare UPIN