Provider Demographics
NPI:1952378978
Name:ICHINOSE, EUGENE J (MD)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:J
Last Name:ICHINOSE
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 1:9228 S MINGO RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:918-592-0999
Mailing Address - Fax:918-592-1021
Practice Address - Street 1:1265 SOUTH UTICA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4243
Practice Address - Country:US
Practice Address - Phone:918-592-0999
Practice Address - Fax:918-592-1021
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209618207R00000X, 207RC0000X, 207RI0011X, 207UN0901X
OK26012207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200198060AMedicaid
OKP00642514OtherMEDICARE RAILROAD
OKP00642514OtherMEDICARE RAILROAD
H56890Medicare UPIN
OK200198060AMedicaid