Provider Demographics
NPI:1124169289
Name:MIYASHITA, JEAN T (MD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:T
Last Name:MIYASHITA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:T
Other - Last Name:MIYASHITA MD INC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:18411 CLARK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3527
Mailing Address - Country:US
Mailing Address - Phone:818-343-1700
Mailing Address - Fax:
Practice Address - Street 1:18411 CLARK ST STE 103
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3527
Practice Address - Country:US
Practice Address - Phone:818-343-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079761207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G59120Medicare UPIN