Provider Demographics
NPI:1114960192
Name:TATSUYAMA, JED JITSUGO (MD)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:JITSUGO
Last Name:TATSUYAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1619 N GREENWOOD STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-543-1130
Mailing Address - Fax:719-561-2764
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-543-1130
Practice Address - Fax:719-561-2764
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO41404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62287338Medicaid
CO62287338Medicaid
COG74828Medicare UPIN