Provider Demographics
NPI:1962502252
Name:NAKANO, PHILLIP HIROTO (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:HIROTO
Last Name:NAKANO
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 1:3096 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-7918
Mailing Address - Country:US
Mailing Address - Phone:770-495-1477
Mailing Address - Fax:770-495-1488
Practice Address - Street 1:3096 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-7918
Practice Address - Country:US
Practice Address - Phone:770-495-1477
Practice Address - Fax:770-495-1488
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024310208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52026987OtherBCBS
GA00486351AMedicaid
GA686583OtherFIRST HEALTH
GAE39465Medicare UPIN
GA52026987OtherBCBS