Provider Demographics
NPI:1801870662
Name:MIYAGISHIMA, BRIAN M (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:MIYAGISHIMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:504 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6917
Mailing Address - Country:US
Mailing Address - Phone:805-349-8514
Mailing Address - Fax:805-349-8958
Practice Address - Street 1:525 PLAZA DR
Practice Address - Street 2:SUITE 204A
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6953
Practice Address - Country:US
Practice Address - Phone:805-925-3030
Practice Address - Fax:805-925-6453
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5781301OtherAETNA
CACB219047OtherMEDICARE ID
P00067428Medicare PIN
CAWG69648GMedicare PIN