Healthcare Provider Details

I. General information

NPI: 1801220710
Provider Name (Legal Business Name): MASATO SUGIURA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MADISON AVENUE TOBIN HALL
SCRANTON PA
18510
US

IV. Provider business mailing address

501 MADISON AVENUE TOBIN HALL
SCRANTON PA
18510
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-2383
  • Fax:
Mailing address:
  • Phone: 570-343-2383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT015563
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: