Healthcare Provider Details

I. General information

NPI: 1922072313
Provider Name (Legal Business Name): MIGUEL ANTONIO TIRADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SEGUINE AVE SUITE 1
STATEN ISLAND NY
10309-3730
US

IV. Provider business mailing address

305 SEGUINE AVE SUITE 1
STATEN ISLAND NY
10309-3730
US

V. Phone/Fax

Practice location:
  • Phone: 718-967-8300
  • Fax: 718-967-8335
Mailing address:
  • Phone: 718-967-8300
  • Fax: 718-967-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number203529
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number203529
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: