Provider Demographics
NPI:1710978622
Name:NISHIYAMA, STEPHEN TAKEO (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TAKEO
Last Name:NISHIYAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:781-487-4340
Mailing Address - Fax:781-487-4341
Practice Address - Street 1:40 SECOND AVE
Practice Address - Street 2:STE 400
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-487-4340
Practice Address - Fax:781-487-4341
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA81412208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA081412OtherTUFTS HEALTH PLAN
MAJ31669OtherBCBS MA
MA3141683Medicaid
F90470Medicare UPIN
MAA21821Medicare PIN