Provider Demographics
NPI:1588643969
Name:YAWATA, EDEN KATSUMASA (DO)
Entity type:Individual
Prefix:MR
First Name:EDEN
Middle Name:KATSUMASA
Last Name:YAWATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:657-241-3600
Mailing Address - Fax:657-241-7708
Practice Address - Street 1:18785 BROOKHURST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7300
Practice Address - Country:US
Practice Address - Phone:714-378-0042
Practice Address - Fax:714-968-9129
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00712395OtherMEDICARE RAILROAD
CA20XA7933Medicaid
CAP00712395OtherMEDICARE RAILROAD
CA20XA7933Medicaid