Provider Demographics
NPI:1720125602
Name:YASUZAWA, SHINICHI STEVE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHINICHI
Middle Name:STEVE
Last Name:YASUZAWA
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 1:1421 S POTOMAC ST STE 220
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4512
Mailing Address - Country:US
Mailing Address - Phone:303-696-0707
Mailing Address - Fax:303-696-0708
Practice Address - Street 1:1421 S POTOMAC ST STE 220
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4512
Practice Address - Country:US
Practice Address - Phone:303-696-0707
Practice Address - Fax:303-696-0708
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01176528Medicaid
COD23319Medicare UPIN
CO01176528Medicaid