Provider Demographics
NPI:1659908168
Name:YONEMOTO, GRANT MICHAEL SHIGERU (DPM)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL SHIGERU
Last Name:YONEMOTO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 MIDDLESEX RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-3325
Mailing Address - Country:US
Mailing Address - Phone:808-348-5746
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-789-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAE5960213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program