Provider Demographics
NPI:1598721227
Name:TACHIBANA, MIKIO (MD)
Entity Type:Individual
Prefix:
First Name:MIKIO
Middle Name:
Last Name:TACHIBANA
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 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 154
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-966-2800
Mailing Address - Fax:714-966-0421
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 154
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-966-2800
Practice Address - Fax:714-966-0421
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A354330OtherBCBS OF CA
CA00A354330Medicaid
CA00A354330Medicaid
CAWA35433AMedicare ID - Type Unspecified