Provider Demographics
NPI:1578660122
Name:THOMAS J, TANAKA, DPM
Entity Type:Organization
Organization Name:THOMAS J, TANAKA, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TANAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-832-7212
Mailing Address - Street 1:17400 IRVINE BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-832-7212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3648213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E36480Medicaid
T95864Medicare UPIN
CA000E36480Medicaid
WE11707Medicare PIN