Provider Demographics
NPI:1629024328
Name:YUASA, SHORTA (MD)
Entity Type:Individual
Prefix:
First Name:SHORTA
Middle Name:
Last Name:YUASA
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 1:295 VARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01853-1802
Mailing Address - Country:US
Mailing Address - Phone:978-937-6161
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2134
Practice Address - Country:US
Practice Address - Phone:978-937-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153944207P00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ17924OtherBCBS
MA3171353Medicaid
MA3171353Medicaid