Provider Demographics
NPI:1992882815
Name:RIVERA MIRANDA, JOSE D (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:D
Last Name:RIVERA MIRANDA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2431 AVE LAS AMERICAS
Mailing Address - Street 2:306 EDIFICIO PORRATA PILA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2113
Mailing Address - Country:US
Mailing Address - Phone:787-841-0574
Mailing Address - Fax:787-841-0574
Practice Address - Street 1:2431 AVE LAS AMERICAS
Practice Address - Street 2:306 EDIFICIO PORRATA PILA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2113
Practice Address - Country:US
Practice Address - Phone:787-841-0574
Practice Address - Fax:787-841-0574
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR123412080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0089311Medicare ID - Type Unspecified
PRG38125Medicare UPIN