Provider Demographics
NPI:1508155839
Name:MITCHELL N. TASAKI
Entity Type:Organization
Organization Name:MITCHELL N. TASAKI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:N
Authorized Official - Last Name:TASAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-242-8877
Mailing Address - Street 1:1885 MAIN ST
Mailing Address - Street 2:STE. 206
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1819
Mailing Address - Country:US
Mailing Address - Phone:808-242-8877
Mailing Address - Fax:808-242-1564
Practice Address - Street 1:1885 MAIN ST
Practice Address - Street 2:STE. 206
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1819
Practice Address - Country:US
Practice Address - Phone:808-242-8877
Practice Address - Fax:808-242-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI9619208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI008697601Medicaid
G56581Medicare UPIN