Provider Demographics
NPI:1275637647
Name:EGUIZABAL, MICHAEL VALERIO (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VALERIO
Last Name:EGUIZABAL
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 SW 117 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4611
Mailing Address - Country:US
Mailing Address - Phone:786-261-6752
Mailing Address - Fax:800-806-9071
Practice Address - Street 1:12970 SW 117 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4611
Practice Address - Country:US
Practice Address - Phone:786-261-6752
Practice Address - Fax:800-806-9071
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20045225100000X
NC10550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212057Medicaid