Provider Demographics
NPI:1104874734
Name:MIRANDER, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MIRANDER
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 1:8711 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6388
Mailing Address - Country:US
Mailing Address - Phone:904-223-2330
Mailing Address - Fax:904-223-3149
Practice Address - Street 1:9035 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6440
Practice Address - Country:US
Practice Address - Phone:954-378-0333
Practice Address - Fax:954-378-0330
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 58452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12988TMedicare PIN
F03394Medicare UPIN