Provider Demographics
NPI:1194173963
Name:NAGATA, IAN (DO)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:NAGATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 MIRAMAR RD STE C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4232
Mailing Address - Country:US
Mailing Address - Phone:858-549-4255
Mailing Address - Fax:858-549-4552
Practice Address - Street 1:7590 MIRAMAR RD STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4232
Practice Address - Country:US
Practice Address - Phone:858-549-4255
Practice Address - Fax:858-549-4552
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-1824208D00000X
CA18031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice