MEDICARE: MIRA MACE MEDICAL SERVICES WEST PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1902760333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRA MACE MEDICAL SERVICES WEST PC

Provider Business Mailing Address
First Line	:	1111B S GOVERNORS AVE STE 39475
Second Line	:
City	:	DOVER
State	:	DE
Zip	:	19904-6903
Country	:	US
Telephone Number	:	332-296-0021
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 AUGUSTINE DR
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95054-3032
Country	:	US
Telephone Number	:	332-296-0021
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	JAGADEESH JAGARLAMUDI
Credential	:
Telephone Number	:	332-296-0021

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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