Provider Demographics
NPI:1104463108
Name:MUNOZ, MIRIAM MARITZA
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MARITZA
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12349 LAKESHORE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3048
Mailing Address - Country:US
Mailing Address - Phone:619-618-6115
Mailing Address - Fax:
Practice Address - Street 1:12349 LAKESHORE DR APT 4
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3048
Practice Address - Country:US
Practice Address - Phone:619-618-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty