Brand Name | PENTAX |
Type of Device | VIDEO UPPER G.I.SCOPE |
Manufacturer (Section D) |
HOYA CORPORATION PENTAX TOKYO OFFICE |
tsutsujigaoka 1-1-110 |
akishima-shi, tokyo 196-0 012 |
JA 196-0012 |
|
Manufacturer (Section G) |
HOYA CORPORATION PENTAX TOKYO OFFICE |
tsutsujigaoka 1-1-110 |
|
akishima-shi, tokyo 196-0 012 |
JA
196-0012
|
|
Manufacturer Contact |
william
goeller
|
3 paragon drive |
montvale, NJ 07645
|
8004315880
|
|
MDR Report Key | 13270571 |
MDR Text Key | 289757948 |
Report Number | 9610877-2022-00142 |
Device Sequence Number | 1 |
Product Code |
FDS
|
UDI-Device Identifier | 04961333129492 |
UDI-Public | 04961333129492 |
Combination Product (y/n) | N |
Reporter Country Code | GM |
PMA/PMN Number | K131902 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Foreign,Distributor |
Reporter Occupation |
Other
|
Type of Report
| Initial,Followup |
Report Date |
06/06/2022 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | EG-2990I |
Was Device Available for Evaluation? |
Yes
|
Is the Reporter a Health Professional? |
No
|
Initial Date Manufacturer Received |
01/12/2022
|
Initial Date FDA Received | 01/17/2022 |
Supplement Dates Manufacturer Received | 01/12/2022
|
Supplement Dates FDA Received | 06/06/2022
|
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 05/30/2012 |
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Patient Sequence Number | 1 |
|
|