Healthcare Provider Details

I. General information

NPI: 1568698439
Provider Name (Legal Business Name): KYLE TAKESHI YAMAMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 LAKESIDE DR STE 100
RENO NV
89509-5285
US

IV. Provider business mailing address

3614 LAKESIDE DR STE 100
RENO NV
89509-5285
US

V. Phone/Fax

Practice location:
  • Phone: 775-525-1712
  • Fax:
Mailing address:
  • Phone: 775-525-1712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number15693
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: