Basic Information
| Provider Information | |||||||||
| NPI: | 1477575207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA-MORENO | ||||||||
| FirstName: | IBELITH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2595 W INTERNATIONAL SPEEDWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321141118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056498100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2595 W INTERNATIONAL SPEEDWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321141118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056498100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 16169 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 261Q00000X | 16169 | PR | N | Ambulatory Health Care Facilities | Clinic/Center | 208D00000X | ACN1390 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 112495900 | 05 | FL | MEDICAID |