Basic Information
| Provider Information | |||||||||
| NPI: | 1225202575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8139725055 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E BRANDON BLVD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OS10347 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000135901 | 05 | FL | MEDICAID | 319144 | 01 | FL | AVMED | OTHER | 1085844 | 01 | FL | CIGNA | OTHER | 46150 | 01 | FL | BC/BS | OTHER | 9012205 | 01 | FL | AETNA | OTHER |