Provider Demographics
NPI:1366517005
Name:ENDO, ATSUSHI (MD)
Entity type:Individual
Prefix:
First Name:ATSUSHI
Middle Name:
Last Name:ENDO
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 1:1600 SW ARCHER RD BOX 112727
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0001
Mailing Address - Country:US
Mailing Address - Phone:352-273-7375
Mailing Address - Fax:352-273-7388
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3706
Practice Address - Country:US
Practice Address - Phone:352-273-7375
Practice Address - Fax:352-273-7388
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140212207QS0010X
CAC152920207Q00000X
MI4301085697207Q00000X
MA266010207QS0010X
GA85016207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103407600Medicaid