Provider Demographics
NPI:1811988090
Name:MIRANDA COLON, MAXIMINO (MD)
Entity type:Individual
Prefix:
First Name:MAXIMINO
Middle Name:
Last Name:MIRANDA COLON
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:PO BOX 1262
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-737-6441
Mailing Address - Fax:787-737-1280
Practice Address - Street 1:CALLE ANDRES ARUZ #166
Practice Address - Street 2:
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-737-6441
Practice Address - Fax:787-737-1280
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E04122Medicare UPIN
80899Medicare ID - Type Unspecified