Healthcare Provider Details

I. General information

NPI: 1801389655
Provider Name (Legal Business Name): TAKAHIRO YAMAGUCHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 01/17/2026
Certification Date: 01/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE FL 7
BOSTON MA
02118-2605
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5946
  • Fax:
Mailing address:
  • Phone: 617-414-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number287972
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP04355
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: