Provider Demographics
NPI:1407670433
Name:SAKUMOTO, TIAGO VINICIUS SR
Entity type:Individual
Prefix:
First Name:TIAGO
Middle Name:VINICIUS
Last Name:SAKUMOTO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5158 NORTHERN FLICKER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-8430
Mailing Address - Country:US
Mailing Address - Phone:689-257-9607
Mailing Address - Fax:
Practice Address - Street 1:1330 BUDINGER AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4123
Practice Address - Country:US
Practice Address - Phone:407-891-2010
Practice Address - Fax:407-891-8211
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE41276207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology