Healthcare Provider Details

I. General information

NPI: 1346751567
Provider Name (Legal Business Name): IRVIN DELEON-MIRANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2017
Last Update Date: 10/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 SE ASTER LN
STUART FL
34994-5721
US

IV. Provider business mailing address

9150 SW 21ST DR
STUART FL
34997-7925
US

V. Phone/Fax

Practice location:
  • Phone: 772-924-6770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier102005400
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: