MEDICARE: YASUO ISHIDA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	33207	MO
2	207Q00000X	Family Medicine Physician	33207	MO

General Provider Information

NPI Number	:	1811973944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YASUO ISHIDA M.D.

Provider Business Mailing Address
First Line	:	6744 CLAYTON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1637
Country	:	US
Telephone Number	:	314-645-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 PROGRESS PKWY # A
Second Line	:
City	:	SULLIVAN
State	:	MO
Zip	:	63080-2359
Country	:	US
Telephone Number	:	573-468-6011
Fax Number	:	573-468-7868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	08/29/2012

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Directions to “ YASUO ISHIDA M.D.” Practice Location

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