Provider Demographics
NPI:1073081311
Name:DESOIZA, MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DESOIZA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATION RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2117
Mailing Address - Country:US
Mailing Address - Phone:631-767-9337
Mailing Address - Fax:
Practice Address - Street 1:1787 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3507
Practice Address - Country:US
Practice Address - Phone:631-767-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028288-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist