Provider Demographics
NPI:1952377756
Name:MIRANDA, GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:MIRANDA
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 1:34167 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-2230
Mailing Address - Country:US
Mailing Address - Phone:510-790-6315
Mailing Address - Fax:
Practice Address - Street 1:34167 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555-2230
Practice Address - Country:US
Practice Address - Phone:510-790-6315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA038721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA038721OtherOTHER PRIVATE INS.PROV.NO
CA00A387212Medicaid
CAA0387210OtherBLUE SHIELD PROVIDER NUM.
CAA0387210OtherBLUE SHIELD PROVIDER NUM.
CAA28707Medicare UPIN