Healthcare Provider Details

I. General information

NPI: 1477089985
Provider Name (Legal Business Name): JEIRYM MIRANDA-TEJADA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 01/29/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030-3876
US

IV. Provider business mailing address

205 E 95TH ST APT 11F
NEW YORK NY
10128-4067
US

V. Phone/Fax

Practice location:
  • Phone: 516-562-4100
  • Fax:
Mailing address:
  • Phone: 646-881-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number323470
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: