Basic Information
| Provider Information | |||||||||
| NPI: | 1336103019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE AZA | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 TILGHMAN ST | ||||||||
| Address2: | LVCMHC INC | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181044354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842219135 | ||||||||
| FaxNumber: | 4842219130 | ||||||||
| Practice Location | |||||||||
| Address1: | 2957 NORTH 5TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191332800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842219135 | ||||||||
| FaxNumber: | 4842219130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 15822 | PR | Y | Emergency Medical Service Providers | Personal Emergency Response Attendant | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.