1912971987 NPI number — YUTAKA WAJIMA M.D.

Table of content: YUTAKA WAJIMA M.D. (NPI 1912971987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912971987 NPI number — YUTAKA WAJIMA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAJIMA
Provider First Name:
YUTAKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912971987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 300087
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78703-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-407-8444
Provider Business Mailing Address Fax Number:
512-407-8097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2304 HANCOCK DR STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78756-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-407-8444
Provider Business Practice Location Address Fax Number:
512-407-8097
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  J-7864 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104617903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104617904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: J-7864 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8R7390 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00305313 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: BH9633 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00211061 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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