Provider Demographics
NPI:1811973944
Name:ISHIDA, YASUO (MD)
Entity type:Individual
Prefix:
First Name:YASUO
Middle Name:
Last Name:ISHIDA
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 1:6744 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1637
Mailing Address - Country:US
Mailing Address - Phone:314-645-6100
Mailing Address - Fax:
Practice Address - Street 1:102 PROGRESS PKWY # A
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:573-468-6011
Practice Address - Fax:573-468-7868
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33207207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A11994Medicare UPIN