Provider Demographics
NPI:1699774836
Name:SUGASAWARA, ROY ISAO (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:ISAO
Last Name:SUGASAWARA
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 1:360 MOBIL AVE
Mailing Address - Street 2:#116
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6325
Mailing Address - Country:US
Mailing Address - Phone:805-484-7967
Mailing Address - Fax:805-389-0057
Practice Address - Street 1:360 MOBIL AVE
Practice Address - Street 2:#116
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6325
Practice Address - Country:US
Practice Address - Phone:805-484-7967
Practice Address - Fax:805-389-0057
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55934208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE04644Medicare UPIN
WG55934EMedicare PIN