Basic Information
Provider Information | |||||||||
NPI: | 1861757890 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YAMAZAKI | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | KIYOSHI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YAMAZAKI | ||||||||
OtherFirstName: | KIYOSHI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 17005 HASTINGS AVE | ||||||||
Address2: |   | ||||||||
City: | PARKER | ||||||||
State: | CO | ||||||||
PostalCode: | 801347657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293121000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 831 S PERRY ST | ||||||||
Address2: | #200 | ||||||||
City: | CASTLE ROCK | ||||||||
State: | CO | ||||||||
PostalCode: | 801041919 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032187774 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2012 | ||||||||
LastUpdateDate: | 10/03/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 66919 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | DR.0056881 | CO | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | DR.0056881 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 59317515 | 05 | CO |   | MEDICAID | DR.0056881 | 01 | CO | COLORADO STATE LICENSE | OTHER |