Healthcare Provider Details

I. General information

NPI: 1811973944
Provider Name (Legal Business Name): YASUO ISHIDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PROGRESS PKWY # A
SULLIVAN MO
63080-2359
US

IV. Provider business mailing address

6744 CLAYTON RD
SAINT LOUIS MO
63117-1637
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-6011
  • Fax: 573-468-7868
Mailing address:
  • Phone: 314-645-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number33207
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33207
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: