Active NPI
Maynard Villavicencio Utayde, PT
- Physical Therapist
- Mishawaka, IN
National Provider Identifier
1699832113
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 05005198A
- Practice address
- 1409 E Day Rd
Mishawaka, IN 46545-3671 - Phone
- (574) 257-9880
- NPI assigned
- Jan 3, 2007
- Last updated
- Jul 17, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 05005198A | IN | Primary |
Addresses
Primary practice location
1409 E Day Rd
Mishawaka, IN 46545-3671
Mailing address
51470 Norwich Dr
Granger, IN 46530-8426
Phone (574) 257-9880
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 05005198A | IN | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1167782400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1468713600000",
"number": "1699832113",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "51470 NORWICH DR",
"city": "GRANGER",
"state": "IN",
"postal_code": "465308426",
"telephone_number": "574-257-9880"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1409 E DAY RD",
"city": "MISHAWAKA",
"state": "IN",
"postal_code": "465453671",
"telephone_number": "574-257-9880"
}
],
"practiceLocations": [],
"basic": {
"last_name": "UTAYDE",
"first_name": "MAYNARD",
"middle_name": "VILLAVICENCIO",
"name_prefix": "Mr.",
"credential": "PT",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-01-03",
"last_updated": "2016-07-17",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "IN",
"license": "05005198A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mishawaka, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.