Provider Demographics
NPI:1215004114
Name:SUGIMOTO, GARY D (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:SUGIMOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9961 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-3910
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine