Provider Demographics
NPI:1962577098
Name:MIRANDA, BLAS ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:BLAS
Middle Name:ALBERTO
Last Name: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 1:8269 NORTH LOOP ROAD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-4234
Mailing Address - Country:US
Mailing Address - Phone:915-591-1615
Mailing Address - Fax:915-591-2875
Practice Address - Street 1:8269 NORTH LOOP ROAD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907-4234
Practice Address - Country:US
Practice Address - Phone:915-591-1615
Practice Address - Fax:915-591-2875
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI68259Medicare UPIN
TX8J6868Medicare PIN