Provider Demographics
NPI:1073741385
Name:YASUDA, MARIKO (MD)
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:
Last Name:YASUDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 LINCOLN ST
Mailing Address - Street 2:DERMATOLOGY RESIDENCY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2138
Mailing Address - Country:US
Mailing Address - Phone:508-334-5971
Mailing Address - Fax:
Practice Address - Street 1:281 LINCOLN ST
Practice Address - Street 2:DERMATOLOGY RESIDENCY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2138
Practice Address - Country:US
Practice Address - Phone:508-334-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA240901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology