Provider Demographics
NPI:1871048074
Name:MACIAS, DWAYNE
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:MACIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:618-441-0482
Practice Address - Street 1:510 W MALONEY AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5489
Practice Address - Country:US
Practice Address - Phone:505-488-2620
Practice Address - Fax:505-488-2668
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic