=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477575207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBELITH MIRANDA-MORENO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1051 KEVSTIN DR
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34744-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-257-8007
-----------------------------------------------------
Fax | 407-490-1309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4189
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-4189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-363-9582
-----------------------------------------------------
Fax | 954-363-9663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ACN1390
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------