Provider Demographics
NPI:1285610519
Name:TSUDA, ROY (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:TSUDA
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:ONE MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6322
Mailing Address - Country:US
Mailing Address - Phone:217-875-5565
Mailing Address - Fax:217-875-4680
Practice Address - Street 1:ONE MEMORIAL DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6322
Practice Address - Country:US
Practice Address - Phone:217-875-5565
Practice Address - Fax:217-875-4680
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072402207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072402Medicaid
C47968Medicare UPIN
IL036072402Medicaid