Individual
GLENN TAKESHI YAMAGATA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1331 N ELM ST STE 200, GREENSBORO, NC 27401-6304
(336) 274-6682
(336) 274-8097
Mailing address
PO BOX 85378, CHICAGO, IL 60689-5378
(336) 274-6682
(336) 274-8097
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
9801565
NC
2085R0204X
Vascular & Interventional Radiology Physician
Primary
9801565
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12189
BCBS
NC
01
—
1608046
UNITED HEALTHCARE
NC
01
—
300100860
RAILROAD MEDICARE
NC
01
—
32127
PARTNERS
NC
01
—
88975
MEDCOST
NC
05
—
8912189
—
NC
Enumeration date
05/18/2006
Last updated
10/02/2025
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