Healthcare Provider Details

I. General information

NPI: 1275705253
Provider Name (Legal Business Name): CARLOS JAVIER GLANVILLE MIRANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2008
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 GODWIN BLVD STE 305
SUFFOLK VA
23434-8158
US

IV. Provider business mailing address

2790 GODWIN BLVD STE 305
SUFFOLK VA
23434-8158
US

V. Phone/Fax

Practice location:
  • Phone: 757-931-4222
  • Fax: 757-934-4111
Mailing address:
  • Phone: 757-931-4222
  • Fax: 757-934-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101252033
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT188562
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101252033
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: