Basic Information
| Provider Information | |||||||||
| NPI: | 1639283534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRANDA-SOUSA | ||||||||
| FirstName: | ALEJANDRO | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 3925992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 4571 COLONIAL BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339661156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392262727 | ||||||||
| FaxNumber: | 2399399876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 227880 | MA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | ME111307 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P01052889 | 01 | FL | RAILROAD MEDICARE | OTHER | 355413 | 01 | FL | AVMED | OTHER | P1000190 | 01 | FL | FREEDOM HEALTH | OTHER | 362828 | 01 | FL | UNIVERSAL HEALTHCARE | OTHER | 14JS5 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER | 6442922 | 01 | FL | CIGNA | OTHER | 14JS5 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 9238059 | 01 | FL | AETNA | OTHER | P941227 | 01 | FL | FREEDOM HEALTH - OPTIMUM | OTHER |