Healthcare Provider Details

I. General information

NPI: 1750125910
Provider Name (Legal Business Name): JOSE MIRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2024
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HOSPITAL AVE # 2346
STUART FL
34994-2346
US

IV. Provider business mailing address

1410 SW BARGELLO AVE
PORT ST LUCIE FL
34953-4741
US

V. Phone/Fax

Practice location:
  • Phone: 772-287-5200
  • Fax:
Mailing address:
  • Phone: 786-252-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9385609
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: