Healthcare Provider Details

I. General information

NPI: 1518308428
Provider Name (Legal Business Name): YOSUKE EBISU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO MAIL STOP CODE 10-5550
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO MAIL STOP CODE 10-5550
ALBUQUERQUE NM
87131
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5666
  • Fax:
Mailing address:
  • Phone: 505-272-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2013-0468
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: