Healthcare Provider Details

I. General information

NPI: 1811988090
Provider Name (Legal Business Name): MAXIMINO MIRANDA COLON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE ANDRES ARUZ #166
GURABO PR
00778
US

IV. Provider business mailing address

PO BOX 1262
GURABO PR
00778
US

V. Phone/Fax

Practice location:
  • Phone: 787-737-6441
  • Fax: 787-737-1280
Mailing address:
  • Phone: 787-737-6441
  • Fax: 787-737-1280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6857
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: