Provider Demographics
NPI:1588619159
Name:NAGAO, MASATO (M D PH D)
Entity Type:Individual
Prefix:
First Name:MASATO
Middle Name:
Last Name:NAGAO
Suffix:
Gender:M
Credentials:M D PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7464
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7464
Mailing Address - Country:US
Mailing Address - Phone:415-206-3103
Mailing Address - Fax:415-206-3872
Practice Address - Street 1:1001 POTRERO AVENUE
Practice Address - Street 2:RM 3A36
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-8811
Practice Address - Fax:415-647-3733
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91764208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A917640Medicaid
CA00A917640Medicaid
139536Medicare UPIN