Healthcare Provider Details

I. General information

NPI: 1679686976
Provider Name (Legal Business Name): BRYCE KIYOSHI YAMAUCHI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W 155TH ST #210
GARDENA CA
90247-4061
US

IV. Provider business mailing address

1300 W 155TH ST #210
GARDENA CA
90247-4061
US

V. Phone/Fax

Practice location:
  • Phone: 310-767-1538
  • Fax: 310-767-1165
Mailing address:
  • Phone: 310-767-1538
  • Fax: 310-767-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3477
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO104
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: