Provider Demographics
NPI:1609165356
Name:YAMAMOTO, SHOTA (MD)
Entity Type:Individual
Prefix:
First Name:SHOTA
Middle Name:
Last Name:YAMAMOTO
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 1:13280 EVENING CREEK DR S STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4109
Mailing Address - Country:US
Mailing Address - Phone:858-546-3800
Mailing Address - Fax:858-546-3900
Practice Address - Street 1:13280 EVENING CREEK DR S STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4109
Practice Address - Country:US
Practice Address - Phone:858-546-3800
Practice Address - Fax:858-546-3900
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1283112085N0700X, 2085R0202X
ARE-140662085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program