Provider Demographics
NPI:1114324233
Name:CAVAZOS, MICHAEL S (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:CAVAZOS
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20410 CENTURY BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR STE 155
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1591
Practice Address - Country:US
Practice Address - Phone:855-546-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41945225100000X
MD26916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA144348Medicare PIN
CACA237473Medicare PIN