1356326474 NPI number — JUAN MIRANDA LOPEZ MD

Table of content: JUAN MIRANDA LOPEZ MD (NPI 1356326474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356326474 NPI number — JUAN MIRANDA LOPEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JUAN
Provider Middle Name:
MIRANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356326474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846173
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-247-7500
Provider Business Mailing Address Fax Number:
410-247-4227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 GEIPE RD STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CATONSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-247-7500
Provider Business Practice Location Address Fax Number:
410-247-4227
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  D62197 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 406269800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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