Provider Demographics
NPI:1780660472
Name:WATANABE, ALYSSA T (MD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:T
Last Name:WATANABE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:T
Other - Last Name:WATANABE LOOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31399
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0399
Mailing Address - Country:US
Mailing Address - Phone:323-442-8541
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG638622085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F40887Medicare UPIN
CAAR540WMedicare PIN