Provider Demographics
NPI:1578570081
Name:MACIAS, SERGIO I (PT)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:I
Last Name:MACIAS
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:PO BOX 5841
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2490
Mailing Address - Country:US
Mailing Address - Phone:928-343-7911
Mailing Address - Fax:928-343-9528
Practice Address - Street 1:1233 N MAIN STREET
Practice Address - Street 2:SUITE 10, 11 & 12
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-9999
Practice Address - Country:US
Practice Address - Phone:928-722-6050
Practice Address - Fax:928-722-6094
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4229225100000X
AZC001071332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00029832OtherMEDICARE RAILROAD
AZ556524Medicaid
AZZ75966Medicare PIN
AZ556524Medicaid