Healthcare Provider Details

I. General information

NPI: 1366517005
Provider Name (Legal Business Name): ATSUSHI ENDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3706
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 112727
GAINESVILLE FL
32610-0001
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7375
  • Fax: 352-273-7388
Mailing address:
  • Phone: 352-273-7375
  • Fax: 352-273-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME140212
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC152920
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301085697
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number266010
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number85016
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: