MEDICARE: DAVID T MIYAMA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	4301051920	MI
2	207Y00000X	Otolaryngology Physician	33184	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0400661	OTHER	MI	HELATHPLUS PROVIDER ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0090129	OTHER	MI	BCBSM PIN

General Provider Information

NPI Number	:	1568443240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID T MIYAMA M.D.

Provider Business Mailing Address
First Line	:	4425 N PORT WASHINGTON RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53212-1082
Country	:	US
Telephone Number	:	414-326-2218
Fax Number	:

Provider Business Practice Location Address
First Line	:	2350 N LAKE DR
Second Line	:	SUITE 406
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4528
Country	:	US
Telephone Number	:	414-271-4141
Fax Number	:	414-271-4343

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	03/18/2016

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Directions to “ DAVID T MIYAMA M.D.” Practice Location

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