Provider Demographics
NPI:1609883842
Name:MIYAMOTO, KEITH Y (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:Y
Last Name:MIYAMOTO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:SUITE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7131
Practice Address - Fax:989-731-6415
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-12-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301032171208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OF96004OtherMEDICARE GROUP NUMBER