1649685298 NPI number — EDGAR JAVIER MIRANDA GONZALEZ

Table of content: DR. JAVAN LEE HORWITZ PSY.D., HSPP (NPI 1457538977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649685298 NPI number — EDGAR JAVIER MIRANDA GONZALEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRANDA GONZALEZ
Provider First Name:
EDGAR
Provider Middle Name:
JAVIER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1649685298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65TH INFANTERY AVE, CARR.3 KM. 8.3
Provider Second Line Business Mailing Address:
HOSPITAL UPR DR. FEDERICO TRILLA
Provider Business Mailing Address City Name:
CAROLINA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-757-1800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65TH INFANTERY AVE, CARR.3 KM. 8.3
Provider Second Line Business Practice Location Address:
HOSPITAL UPR DR. FEDERICO TRILLA
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-757-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2014

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: 207P00000X , with the licence number:  32410-R , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 021431700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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