Healthcare Provider Details

I. General information

NPI: 1245499078
Provider Name (Legal Business Name): ANTHONY LOREN MIRANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 STONY BROOK CIR
JACKSON GA
30233-4571
US

IV. Provider business mailing address

2660 W COVELL BLVD
DAVIS CA
95616-5645
US

V. Phone/Fax

Practice location:
  • Phone: 209-306-4796
  • Fax: 478-247-8448
Mailing address:
  • Phone: 530-747-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number070199
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTPME1727
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC165064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: