Provider Demographics
NPI:1629418355
Name:MIEZA, MARIA ANGELICA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ANGELICA
Last Name:MIEZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 E 84TH ST
Mailing Address - Street 2:20C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4423
Mailing Address - Country:US
Mailing Address - Phone:212-861-7103
Mailing Address - Fax:212-504-3072
Practice Address - Street 1:351 E 84TH ST
Practice Address - Street 2:20C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-4423
Practice Address - Country:US
Practice Address - Phone:212-861-7103
Practice Address - Fax:212-504-3072
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1073062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00109009Medicaid
031124Medicare PIN