Provider Demographics
NPI:1366916231
Name:MIRANDA, UBALDO A
Entity type:Individual
Prefix:
First Name:UBALDO
Middle Name:A
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:UBALDO
Other - Middle Name:A
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3218 HILLSDALE LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7562
Mailing Address - Country:US
Mailing Address - Phone:786-241-3749
Mailing Address - Fax:
Practice Address - Street 1:3218 HILLSDALE LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7562
Practice Address - Country:US
Practice Address - Phone:407-738-4349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME147214208D00000X
FLHSE27900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108267400Medicaid