Healthcare Provider Details

I. General information

NPI: 1134680135
Provider Name (Legal Business Name): MAYA AMADEA YABUMOTO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N WESTMORELAND RD
LAKE FOREST IL
60045-1658
US

IV. Provider business mailing address

333 CITY BLVD W STE 400
ORANGE CA
92868-2994
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-5600
  • Fax: 847-535-7203
Mailing address:
  • Phone: 630-363-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number179856
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036164279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: