Healthcare Provider Details

I. General information

NPI: 1598707598
Provider Name (Legal Business Name): MASANORI ICHISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W 168TH ST # MC28
NEW YORK NY
10032-3725
US

IV. Provider business mailing address

630 W 168TH ST # MC28
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-1948
  • Fax: 212-305-5777
Mailing address:
  • Phone: 212-305-1948
  • Fax: 212-305-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number238962
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number238962-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: