Provider Demographics
NPI:1679687479
Name:IMAMURA, YOICHI CHARLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:YOICHI
Middle Name:CHARLEY
Last Name:IMAMURA
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 1:7235 WILTON CHASE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-1268
Mailing Address - Country:US
Mailing Address - Phone:937-207-9501
Mailing Address - Fax:614-407-0511
Practice Address - Street 1:210 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-1115
Practice Address - Country:US
Practice Address - Phone:740-845-7000
Practice Address - Fax:740-845-7701
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070875208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2025267Medicaid
OH11018253124506OtherRR MCR
OH110182531OtherRAILROAD MEDICARE PTAN
000000035503OtherANTHEM
OH0403252OtherUHC
101046OtherBLACK LUNG
341875779027OtherCARESOURCE
OH0403252OtherUHC
OH110182531OtherRAILROAD MEDICARE PTAN
G43954Medicare UPIN