Healthcare Provider Details

I. General information

NPI: 1407156748
Provider Name (Legal Business Name): JORGE MIRANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 102 KM 36.0 #1 BO. MINILLAS
SAN GERMAN PR
00683
US

IV. Provider business mailing address

PO BOX 1675
SAN GERMAN PR
00683-1675
US

V. Phone/Fax

Practice location:
  • Phone: 787-978-7225
  • Fax: 787-680-0814
Mailing address:
  • Phone: 787-978-7225
  • Fax: 787-978-7225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18082
License Number StatePR

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: