Provider Demographics
NPI:1700914116
Name:YASUMOTO, ERIC K (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:K
Last Name:YASUMOTO
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 1:5222 COSUMNES DR APT 272
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7221
Mailing Address - Country:US
Mailing Address - Phone:216-337-8582
Mailing Address - Fax:
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:# 110
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-334-4416
Practice Address - Fax:209-371-0119
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA700702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A700700Medicaid
CA00A700705Medicare PIN
CAP00424832Medicare PIN
CA00A700707Medicare PIN
CA00A700703Medicare PIN
CA00A700706Medicare PIN
CA00A700700Medicaid
CA00A700702Medicare PIN
CA00A700700Medicare PIN
CA00A700704Medicare PIN