Provider Demographics
NPI:1912971987
Name:WAJIMA, YUTAKA (MD)
Entity Type:Individual
Prefix:
First Name:YUTAKA
Middle Name:
Last Name:WAJIMA
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:PO BOX 300087
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0002
Mailing Address - Country:US
Mailing Address - Phone:512-407-8444
Mailing Address - Fax:512-407-8097
Practice Address - Street 1:2304 HANCOCK DR STE 4
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-2540
Practice Address - Country:US
Practice Address - Phone:512-407-8444
Practice Address - Fax:512-407-8097
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ-7864207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104617903Medicaid
TX104617904Medicaid
TXJ-7864OtherSTATE LICENSE
8R7390OtherBLUE CROSS
P00305313OtherMEDICARE RAILROAD
BH9633OtherBLUE CROSS
P00211061OtherMEDICARE RAILROAD
P00305313OtherMEDICARE RAILROAD
8D2016Medicare PIN
G50686Medicare UPIN
TX104617904Medicaid