Provider Demographics
NPI:1710009519
Name:ITO, YUJI ROBERT (CPO)
Entity Type:Individual
Prefix:
First Name:YUJI
Middle Name:ROBERT
Last Name:ITO
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1571
Mailing Address - Country:US
Mailing Address - Phone:704-957-5375
Mailing Address - Fax:
Practice Address - Street 1:1420 ELLEN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5173
Practice Address - Country:US
Practice Address - Phone:704-635-7029
Practice Address - Fax:704-635-7495
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NC224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795313Medicaid
NC674650001OtherPTAN
NC7702811Medicaid
NC674650001OtherPTAN