Healthcare Provider Details

I. General information

NPI: 1700995073
Provider Name (Legal Business Name): IKUYO YAMAGUCHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4211
  • Fax:
Mailing address:
  • Phone: 405-271-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00041921
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD00041921
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberP8827
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: