Provider Demographics
NPI:1306180583
Name:WIRTH, MICHAEL (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WIRTH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HAWKINS AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2366
Mailing Address - Country:US
Mailing Address - Phone:631-981-7422
Mailing Address - Fax:631-981-2490
Practice Address - Street 1:650 HAWKINS AVE
Practice Address - Street 2:STE 4
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2366
Practice Address - Country:US
Practice Address - Phone:631-981-7422
Practice Address - Fax:631-981-2490
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist