Provider Demographics
NPI:1659335750
Name:KURITA, GEORGE I JR (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:I
Last Name:KURITA
Suffix:JR
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 1:1812 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4547
Mailing Address - Country:US
Mailing Address - Phone:931-552-1352
Mailing Address - Fax:931-551-8226
Practice Address - Street 1:1812 HAYNES ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-552-1352
Practice Address - Fax:931-551-8226
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10709207N00000X
KY24341207N00000X
IN01080810A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
621035358OtherTIN
TN3166021Medicare PIN