Provider Demographics
NPI:1053352435
Name:MIYAZAKI, DOUGLAS WAYNE (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:MIYAZAKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-1970
Mailing Address - Fax:336-774-8601
Practice Address - Street 1:770 HIGHLAND OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7105
Practice Address - Country:US
Practice Address - Phone:367-181-9703
Practice Address - Fax:336-774-8601
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36576207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8959811Medicaid
NC2201586AMedicare PIN
NCF85446Medicare UPIN
NC8959811Medicaid