Provider Demographics
NPI:1265900609
Name:TUD, JUAN CARLOS (CLS, CCP)
Entity type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:
Last Name:TUD
Suffix:
Gender:M
Credentials:CLS, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 FERNANDO AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-2814
Mailing Address - Country:US
Mailing Address - Phone:515-865-5471
Mailing Address - Fax:
Practice Address - Street 1:250 FERNANDO AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-2814
Practice Address - Country:US
Practice Address - Phone:515-865-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA999074242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
999074OtherAMERICAN BOARD OF CARDIOVASCULAR PERFUSION