1669801023 NPI number — JOHNNY MIRANDA B.A

Table of content: JOHNNY MIRANDA B.A (NPI 1669801023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669801023 NPI number — JOHNNY MIRANDA B.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRANDA
Provider First Name:
JOHNNY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.A
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:
1669801023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 NORMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01089-5003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-736-8329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01104-3301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-736-0395
Provider Business Practice Location Address Fax Number:
413-734-1651
Provider Enumeration Date:
11/06/2013

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 042622756 . This is a "COMMONWEALTH CARE ALLIANCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1307576 . This is a "MBHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 12529 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1307576 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8443 . This is a "BMC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1022610 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1022610 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 997203 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y10086 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1022610 . This is a "BEACON/BMC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 71756 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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