Healthcare Provider Details

I. General information

NPI: 1710978622
Provider Name (Legal Business Name): STEPHEN TAKEO NISHIYAMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SECOND AVE STE 400
WALTHAM MA
02451
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 781-487-4340
  • Fax: 781-487-4341
Mailing address:
  • Phone: 781-487-4340
  • Fax: 781-487-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81412
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: