Provider Demographics
NPI:1366583395
Name:AMYZIAL, MICHAEL DAVID (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:AMYZIAL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S. WICKHAM RD, STE 101
Mailing Address - Street 2:
Mailing Address - City:W. MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904
Mailing Address - Country:US
Mailing Address - Phone:321-952-9993
Mailing Address - Fax:321-952-9997
Practice Address - Street 1:630 S. WICKHAM RD, STE 101
Practice Address - Street 2:
Practice Address - City:W. MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-952-9993
Practice Address - Fax:321-952-9997
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00621100111N00000X
FLCH9903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU98260Medicare UPIN