Provider Demographics
NPI:1063524700
Name:UDO, TOSHIAKI (PHD)
Entity type:Individual
Prefix:DR
First Name:TOSHIAKI
Middle Name:
Last Name:UDO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2606
Mailing Address - Country:US
Mailing Address - Phone:626-289-5681
Mailing Address - Fax:
Practice Address - Street 1:97 W BELLEVUE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2501
Practice Address - Country:US
Practice Address - Phone:626-282-5744
Practice Address - Fax:626-795-3527
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15090103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY150900Medicaid
CAPSY150900Medicaid