Healthcare Provider Details

I. General information

NPI: 1013335579
Provider Name (Legal Business Name): OLGA NYDIA MIRANDA VICENTE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E 25TH ST
HIALEAH FL
33013-3810
US

IV. Provider business mailing address

8600 NW 41ST ST
DORAL FL
33166-6202
US

V. Phone/Fax

Practice location:
  • Phone: 305-642-5366
  • Fax: 305-644-6407
Mailing address:
  • Phone: 56-425-3663
  • Fax: 305-644-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME130255
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: