Provider Demographics
NPI:1568443240
Name:MIYAMA, DAVID T (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:MIYAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-326-2218
Mailing Address - Fax:
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 406
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-271-4141
Practice Address - Fax:414-271-4343
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051920207Y00000X
WI33184207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0400661OtherHELATHPLUS PROVIDER ID
MI4172040Medicaid
MI0090129OtherBCBSM PIN
MIF30321Medicare UPIN