Provider Demographics
NPI:1306618459
Name:MIYAZATO, ANDREW PARK (OTD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:PARK
Last Name:MIYAZATO
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17519 DAPHNE AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-3518
Mailing Address - Country:US
Mailing Address - Phone:310-956-6190
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:805-883-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist