Provider Demographics
NPI:1538427331
Name:MAYORGA, MIGUEL ANGEL (DPT)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MAYORGA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2512
Mailing Address - Country:US
Mailing Address - Phone:201-968-0303
Mailing Address - Fax:201-968-0330
Practice Address - Street 1:277 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2512
Practice Address - Country:US
Practice Address - Phone:201-968-0303
Practice Address - Fax:201-968-0330
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01435700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist