Provider Demographics
NPI:1215112347
Name:EDWARD P. MIRANDA MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:EDWARD P. MIRANDA MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-379-9015
Mailing Address - Street 1:77 VAN NESS AVENUE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102
Mailing Address - Country:US
Mailing Address - Phone:415-379-9015
Mailing Address - Fax:415-379-9045
Practice Address - Street 1:77 VAN NESS AVENUE
Practice Address - Street 2:SUITE 302
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102
Practice Address - Country:US
Practice Address - Phone:415-379-9015
Practice Address - Fax:415-379-9045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82349208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ06241ZMedicare PIN