Provider Demographics
NPI:1033313580
Name:YAMAGUCHI, MARK K (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:YAMAGUCHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2619
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:952-977-3459
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52910207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033313580Medicaid
IN000000614543OtherANTHEM PROVIDER NUMBER
MN1033313580Medicaid
IN200863980Medicaid
IN815500W5Medicare PIN
WI1033313580Medicaid
MN050002374Medicare PIN
MN1033313580Medicaid