Healthcare Provider Details

I. General information

NPI: 1780995035
Provider Name (Legal Business Name): KAORU MIYAZAKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 BRADENTON AVE STE A
DUBLIN OH
43017-7567
US

IV. Provider business mailing address

5100 BRADENTON AVE STE A
DUBLIN OH
43017-7567
US

V. Phone/Fax

Practice location:
  • Phone: 614-766-5500
  • Fax: 614-489-6391
Mailing address:
  • Phone: 614-766-5500
  • Fax: 614-489-6391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number79366
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4285
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number300988
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.098992
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: