Provider Demographics
NPI:1386865822
Name:ISHIYAMA, TAKAAKI (MD)
Entity Type:Individual
Prefix:
First Name:TAKAAKI
Middle Name:
Last Name:ISHIYAMA
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:SLU CARE ACADEMIC PAVILION
Mailing Address - Street 2:1008 SOUTH SPRING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-257-8222
Mailing Address - Fax:314-577-8019
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022989207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1386865822Medicaid
MO1386865822Medicaid