Provider Demographics
NPI:1164413613
Name:TANABE, KENNETH KENJI (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KENJI
Last Name:TANABE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:YAW 7B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-3868
Practice Address - Fax:617-724-3895
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78104208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3114015Medicaid
MAJ13876OtherBCBS MA
MA078104OtherTUFTS HEALTH PLAN
MAJ13876Medicare ID - Type Unspecified
MAJ13876OtherBCBS MA