Provider Demographics
NPI:1770364838
Name:ISHIGAMI, SHUTA
Entity type:Individual
Prefix:
First Name:SHUTA
Middle Name:
Last Name:ISHIGAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RAKAIA WAY
Mailing Address - Street 2:UNIT 1204
Mailing Address - City:MELBORUNE
Mailing Address - State:VIC
Mailing Address - Zip Code:03008
Mailing Address - Country:AU
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2351
Practice Address - Country:US
Practice Address - Phone:832-822-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48140208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)