Provider Demographics
NPI:1518144468
Name:ORTHOPAEDIC SPORTS MEDICINE
Entity Type:Organization
Organization Name:ORTHOPAEDIC SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:KOJI
Authorized Official - Last Name:YAMAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:817-283-0806
Mailing Address - Street 1:425 WESTPARK WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3751
Mailing Address - Country:US
Mailing Address - Phone:817-283-0806
Mailing Address - Fax:817-545-7569
Practice Address - Street 1:425 WESTPARK WAY
Practice Address - Street 2:SUITE A
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3751
Practice Address - Country:US
Practice Address - Phone:817-283-0806
Practice Address - Fax:817-545-7569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5291207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0072KYOtherBCBS
TXB27709Medicare PIN