Healthcare Provider Details

I. General information

NPI: 1588722748
Provider Name (Legal Business Name): MORIO MIYAMOTO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 OLIVE ST SUITE 420
SAINT LOUIS MO
63101-2338
US

IV. Provider business mailing address

720 OLIVE ST SUITE 420
SAINT LOUIS MO
63101-2338
US

V. Phone/Fax

Practice location:
  • Phone: 314-231-0581
  • Fax: 314-231-2690
Mailing address:
  • Phone: 314-231-0581
  • Fax: 314-231-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT2320
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: