Provider Demographics
NPI:1467632232
Name:MICABALO, IAN MARI VIRAY (PT)
Entity Type:Individual
Prefix:
First Name:IAN MARI
Middle Name:VIRAY
Last Name:MICABALO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 MADISON AVE APT 12C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-2236
Mailing Address - Country:US
Mailing Address - Phone:646-479-2201
Mailing Address - Fax:
Practice Address - Street 1:37 W 26TH ST RM 302
Practice Address - Street 2:NY,NY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1047
Practice Address - Country:US
Practice Address - Phone:718-285-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ23881Medicare PIN