Basic Information
| Provider Information | |||||||||
| NPI: | 1861870545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUZUKI | ||||||||
| FirstName: | TAISEI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 BALD HILL RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651013703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713731820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 765 KENILWORTH TER NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200191898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023888160 | ||||||||
| FaxNumber: | 2025488600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | DO034756 | DC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1861870545 | 05 | DC | MEDICAID |