Provider Demographics
NPI:1841219482
Name:MIYA, GARY Y (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:Y
Last Name:MIYA
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 1:4060 4TH AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2121
Mailing Address - Country:US
Mailing Address - Phone:619-298-7109
Mailing Address - Fax:619-298-8466
Practice Address - Street 1:4060 4TH AVE STE 410
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2121
Practice Address - Country:US
Practice Address - Phone:619-298-7109
Practice Address - Fax:619-298-8466
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83926174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG83926Medicare ID - Type UnspecifiedLICENSE
CAG54407Medicare UPIN