Healthcare Provider Details

I. General information

NPI: 1265900609
Provider Name (Legal Business Name): JUAN CARLOS TUD CLS, CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2018
Last Update Date: 11/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 FERNANDO AVE
PALO ALTO CA
94306-2814
US

IV. Provider business mailing address

250 FERNANDO AVE
PALO ALTO CA
94306-2814
US

V. Phone/Fax

Practice location:
  • Phone: 515-865-5471
  • Fax:
Mailing address:
  • Phone: 515-865-5471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number999074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: