Provider Demographics
NPI:1477385029
Name:KOYAMA, TAIJIRO (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TAIJIRO
Middle Name:
Last Name:KOYAMA
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9327 STATE ROUTE 682 APT 214
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:585-815-5344
Mailing Address - Fax:
Practice Address - Street 1:200 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:585-815-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0070392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer