Basic Information
| Provider Information | |||||||||
| NPI: | 1568443240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIYAMA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143262218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2350 N LAKE DR | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532114528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142714141 | ||||||||
| FaxNumber: | 4142714343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4301051920 | MI | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 33184 | WI | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0400661 | 01 | MI | HELATHPLUS PROVIDER ID | OTHER | 4172040 | 05 | MI | MEDICAID | 0090129 | 01 | MI | BCBSM PIN | OTHER |