Healthcare Provider Details

I. General information

NPI: 1609165356
Provider Name (Legal Business Name): SHOTA YAMAMOTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13280 EVENING CREEK DR S STE 110
SAN DIEGO CA
92128-4109
US

IV. Provider business mailing address

13280 EVENING CREEK DR S STE 110
SAN DIEGO CA
92128-4109
US

V. Phone/Fax

Practice location:
  • Phone: 858-546-3800
  • Fax: 858-546-3900
Mailing address:
  • Phone: 858-546-3800
  • Fax: 858-546-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA10638200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA128311
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA128311
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-14066
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number58381
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: