1568443240 NPI number — DAVID T MIYAMA M.D.

Table of content: DAVID T MIYAMA M.D. (NPI 1568443240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568443240 NPI number — DAVID T MIYAMA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIYAMA
Provider First Name:
DAVID
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1568443240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 N PORT WASHINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-326-2218
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 N LAKE DR
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-4528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-271-4141
Provider Business Practice Location Address Fax Number:
414-271-4343
Provider Enumeration Date:
11/09/2005

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: 207Y00000X , with the licence number:  4301051920 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 33184 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0400661 . This is a "HELATHPLUS PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4172040 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0090129 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com