Healthcare Provider Details

I. General information

NPI: 1538642319
Provider Name (Legal Business Name): SHUICHI YOSHITAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 06/30/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

106 E SQUIRE DR APT 5
ROCHESTER NY
14623-1828
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2735
  • Fax:
Mailing address:
  • Phone: 585-451-5863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number294772
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number272442
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: