Healthcare Provider Details

I. General information

NPI: 1407895006
Provider Name (Legal Business Name): RAUL MIRANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 VICTORIA ST STE. 2K
COSTA MESA CA
92627-1974
US

IV. Provider business mailing address

272 VICTORIA ST STE. 2K
COSTA MESA CA
92627-1974
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-1631
  • Fax: 949-548-7475
Mailing address:
  • Phone: 949-646-1631
  • Fax: 949-548-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA049913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: