Healthcare Provider Details

I. General information

NPI: 1578908448
Provider Name (Legal Business Name): LISA ANN MIYATAKE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PERKINS SQ
AKRON OH
44308-1063
US

IV. Provider business mailing address

1 PERKINS SQ ED ADMINISTRATION
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-4440
  • Fax: 330-543-4467
Mailing address:
  • Phone: 330-543-8452
  • Fax: 330-543-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.012073
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: