Healthcare Provider Details

I. General information

NPI: 1245213859
Provider Name (Legal Business Name): WARREN Y ISHIDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH AVE NO CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 SIXTH AVE NO CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax:
Mailing address:
  • Phone: 320-252-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number48150
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: