Provider Demographics
NPI:1316940943
Name:DE MIRANDA, GILBERTO L (MD)
Entity type:Individual
Prefix:DR
First Name:GILBERTO
Middle Name:L
Last Name:DE 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 1:6517 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-4062
Mailing Address - Country:US
Mailing Address - Phone:954-983-9191
Mailing Address - Fax:
Practice Address - Street 1:6517 TAFT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-4062
Practice Address - Country:US
Practice Address - Phone:954-983-9191
Practice Address - Fax:954-983-1152
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1208208D00000X
PR11202208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG 27584Medicare UPIN
PR88098Medicare ID - Type Unspecified