MEDICARE: DR. TOSHIAKI UDO PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY15090	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063524700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOSHIAKI UDO PH.D.

Provider Business Mailing Address
First Line	:	2270 ADAIR ST
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2606
Country	:	US
Telephone Number	:	626-289-5681
Fax Number	:

Provider Business Practice Location Address
First Line	:	97 W BELLEVUE DR
Second Line	:	SUITE 1
City	:	PASADENA
State	:	CA
Zip	:	91105-2501
Country	:	US
Telephone Number	:	626-282-5744
Fax Number	:	626-795-3527

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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