Provider Demographics
NPI:1598718066
Name:YAMAGATA, GLENN TAKESHI (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:TAKESHI
Last Name:YAMAGATA
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 63112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3112
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 N ELM ST STE 200
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6304
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98015652085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC88975OtherMEDCOST
NC300100860OtherRAILROAD MEDICARE
NC1608046OtherUNITED HEALTHCARE
NC32127OtherPARTNERS
NC12189OtherBCBS
NC8912189Medicaid
NC88975OtherMEDCOST
NC2276294Medicare ID - Type Unspecified
NC8912189Medicaid