Provider Demographics
NPI:1336103019
Name:DE AZA, MIGUEL ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANTONIO
Last Name:DE AZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2030 TILGHMAN ST
Mailing Address - Street 2:LVCMHC INC
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-4354
Mailing Address - Country:US
Mailing Address - Phone:484-221-9135
Mailing Address - Fax:484-221-9130
Practice Address - Street 1:2957 NORTH 5TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2800
Practice Address - Country:US
Practice Address - Phone:484-221-9135
Practice Address - Fax:484-221-9130
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR15822146D00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health