Provider Demographics
NPI:1205831583
Name:TARZANA ENDOCRINE & MEDICAL GROUP
Entity Type:Organization
Organization Name:TARZANA ENDOCRINE & MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TANOUYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-996-5700
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:STE 601
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2831
Mailing Address - Country:US
Mailing Address - Phone:818-996-5700
Mailing Address - Fax:818-996-1649
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:STE 601
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2831
Practice Address - Country:US
Practice Address - Phone:818-996-5700
Practice Address - Fax:818-996-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X, 207RE0101X
CACLF298291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19-139OtherDHS MEDICAL WASTE REG #
CAFAC00002669OtherRADIATION MACHINE DEPT OF PUBLIC HEALTH, CALIF.
CAT0796OtherRAILROAD GROUP NUMBER
CA05D0559244OtherCLIA LICENSE STE 300
CA19359OtherFICTITIOUS NAME PERMIT
CA110061982OtherRAILROAD GROUP RENDERING
CAYYY40048YOtherBLUE SHIELD OF CALIFORNIA
CACAL000056694OtherRADIOLOGIC LICENSE
CACLF298OtherSTATE LABORATORY LICENSE
CACPP 315971OtherSTATE LABORATORY LICENSE SUITE 601
CAYYY40048YMedicaid
CA05D0889138OtherCLIA LICENSE STE 601
CA19359OtherFICTITIOUS NAME PERMIT