Provider Demographics
NPI:1316039464
Name:NADATA, MICHAEL DAVID (CPO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:NADATA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1315
Mailing Address - Country:US
Mailing Address - Phone:516-239-0990
Mailing Address - Fax:516-239-6555
Practice Address - Street 1:214 E SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1315
Practice Address - Country:US
Practice Address - Phone:516-239-0990
Practice Address - Fax:516-239-6555
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02595480Medicaid
NY02595480Medicaid