Provider Demographics
NPI:1629047188
Name:YAMADA, KENTARO EMIL (MD)
Entity Type:Individual
Prefix:
First Name:KENTARO
Middle Name:EMIL
Last Name:YAMADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1040 UNIVERSITY AVE STE B209A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-7328
Mailing Address - Country:US
Mailing Address - Phone:619-299-1100
Mailing Address - Fax:619-299-7156
Practice Address - Street 1:4094 FOURTH AVE
Practice Address - Street 2:STE 203
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2143
Practice Address - Country:US
Practice Address - Phone:619-299-1100
Practice Address - Fax:619-299-7156
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95387207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A953870Medicaid
CAA95387Medicare PIN
I31204Medicare UPIN