=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023270113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YORCKAY C ISHIZAWAR MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 TEMPLE AVE
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-526-0107
-----------------------------------------------------
Fax | 804-526-4466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 TEMPLE AVE
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-526-0107
-----------------------------------------------------
Fax | 804-526-4466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YORCKAY C ISHIZAWAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 804-536-0107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 02303295
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------