Provider Demographics
NPI:1154398568
Name:KY-MIYASAKA, ALEX JENNY (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:JENNY
Last Name:KY-MIYASAKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:J
Other - Last Name:KY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:BOX 1263
Mailing Address - Street 2:1 GUSTAVE L LEVY PL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-1303
Mailing Address - Fax:212-534-2654
Practice Address - Street 1:5 EAST 98TH STREET
Practice Address - Street 2:14TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-1303
Practice Address - Fax:212-534-2654
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203197208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02081854Medicaid
H15568Medicare UPIN
NY000361Medicare ID - Type Unspecified