MEDICARE: BUSHIDO BARIATRIC CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist
2	133V00000X	Registered Dietitian
3	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1902193410	OTHER	PA	NPPES
2	1790070605	OTHER		NPPES

General Provider Information

NPI Number	:	1932784998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUSHIDO BARIATRIC CENTER

Provider Business Mailing Address
First Line	:	402 N WEST ST
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-2543
Country	:	US
Telephone Number	:	907-350-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 N WEST ST
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-2543
Country	:	US
Telephone Number	:	907-350-5571
Fax Number	:

Authorized Official
Title or Position	:	SURGEON
Name	:	DR. LISSA CHRISTINA SAKATA
Credential	:	MD, MPH
Telephone Number	:	907-350-5571

Provider Enumeration Date	:	03/11/2021
Last Update Date	:	03/11/2021

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