Healthcare Provider Details

I. General information

NPI: 1033732243
Provider Name (Legal Business Name): TAD KIYOSHI SUGIYAMA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 W MARTIN ST
SAN ANTONIO TX
78207-0903
US

IV. Provider business mailing address

903 W MARTIN ST # MS 49-2
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-0572
  • Fax: 210-358-5940
Mailing address:
  • Phone: 201-358-5909
  • Fax: 210-358-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU4643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: