Healthcare Provider Details

I. General information

NPI: 1699065771
Provider Name (Legal Business Name): SHOJI ISHIGAMI M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 N TENNESSEE AVE STE 104
MARTINSBURG WV
25401-9401
US

IV. Provider business mailing address

9909 MEDICAL CENTER DR
ROCKVILLE MD
20850-6361
US

V. Phone/Fax

Practice location:
  • Phone: 304-596-5160
  • Fax: 304-596-5161
Mailing address:
  • Phone: 240-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number28503
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD0081409
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: