Provider Demographics
NPI:1376955831
Name:YANAGISAWA, MIO
Entity Type:Individual
Prefix:
First Name:MIO
Middle Name:
Last Name:YANAGISAWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 CLIFTON RD NE BLDG C
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-3307
Mailing Address - Fax:404-778-4255
Practice Address - Street 1:1279 HIGHWAY 54 W STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4551
Practice Address - Country:US
Practice Address - Phone:770-719-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA85457208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
925717241OtherPPS