Provider Demographics
NPI:1588722748
Name:MIYAMOTO, MORIO (OD)
Entity type:Individual
Prefix:DR
First Name:MORIO
Middle Name:
Last Name:MIYAMOTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 OLIVE ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-2338
Mailing Address - Country:US
Mailing Address - Phone:314-231-0581
Mailing Address - Fax:314-231-2690
Practice Address - Street 1:720 OLIVE ST
Practice Address - Street 2:SUITE 420
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-2338
Practice Address - Country:US
Practice Address - Phone:314-231-0581
Practice Address - Fax:314-231-2690
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2320152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310753819Medicaid
MO000007673OtherMEDICARE PTAN
MO0791940001OtherMEDICARE REGIOND/DMERC
MO000007673OtherMEDICARE PTAN
MOT42717Medicare UPIN