Provider Demographics
NPI:1235235235
Name:TANAKA, KEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:TANAKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011
Mailing Address - Country:US
Mailing Address - Phone:818-790-1138
Mailing Address - Fax:
Practice Address - Street 1:1039 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011
Practice Address - Country:US
Practice Address - Phone:818-790-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U28632Medicare UPIN
OP5488Medicare ID - Type Unspecified