Provider Demographics
NPI:1679686976
Name:YAMAUCHI, BRYCE KIYOSHI (DPM)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:KIYOSHI
Last Name:YAMAUCHI
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 1:1300 W 155TH ST
Mailing Address - Street 2:#210
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4061
Mailing Address - Country:US
Mailing Address - Phone:310-767-1538
Mailing Address - Fax:310-767-1165
Practice Address - Street 1:1300 W 155TH ST
Practice Address - Street 2:#210
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4061
Practice Address - Country:US
Practice Address - Phone:310-767-1538
Practice Address - Fax:310-767-1165
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3477213E00000X
HIPO104213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34772Medicaid
CA000E34772Medicaid
CAE3477AMedicare ID - Type Unspecified