Healthcare Provider Details

I. General information

NPI: 1255857504
Provider Name (Legal Business Name): GENGO SUNAGAWA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRTUA HEALTH AND WELLNESS CENTER CHERRY HILL 1 BRACE ROAD, SUITE H
CHERRY HILL NJ
08034
US

IV. Provider business mailing address

301 LIPPINCOTT DRIVE SUITE 410
MARLTON NJ
08053
US

V. Phone/Fax

Practice location:
  • Phone: 856-547-0389
  • Fax: 856-325-4293
Mailing address:
  • Phone: 856-547-0389
  • Fax: 856-325-4293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD463661
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number25MA11210200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberLT000773
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: