Healthcare Provider Details

I. General information

NPI: 1104362029
Provider Name (Legal Business Name): SHO KUDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141-11 SAKEMI TAKAGI HOSPITAL
OKAWA FUKUOKA
8310016
JP

IV. Provider business mailing address

5-7-62 OOTAKARA
SAGA SAGA
8400811
JP

V. Phone/Fax

Practice location:
  • Phone: 81944870001
  • Fax: 81944870025
Mailing address:
  • Phone: 81952287263
  • Fax: 81952287263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number022675
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: