Provider Demographics
NPI:1407902760
Name:TANABE, CALVIN (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:TANABE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:STE 440
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-297-3766
Mailing Address - Fax:503-297-8128
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 440
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-3766
Practice Address - Fax:503-297-8128
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD6702207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
014WCJQWAMedicare ID - Type Unspecified
C91583Medicare UPIN