Healthcare Provider Details

I. General information

NPI: 1154360840
Provider Name (Legal Business Name): LOUELLA M MIRANDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88-31 55TH AVENUE SUITE 201
ELMHURST NY
11373-4686
US

IV. Provider business mailing address

55 WATER ST FL 2
NEW YORK NY
10041-0010
US

V. Phone/Fax

Practice location:
  • Phone: 718-899-6600
  • Fax: 718-606-3881
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number193873
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier01723642
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: