Provider Demographics
NPI:1619099769
Name:TANOUYE, DAVID ROY (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROY
Last Name:TANOUYE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:25651 ATLANTIC OCEAN DR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8841
Mailing Address - Country:US
Mailing Address - Phone:949-707-2740
Mailing Address - Fax:949-421-1194
Practice Address - Street 1:25651 ATLANTIC OCEAN DR
Practice Address - Street 2:SUITE A-1
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8841
Practice Address - Country:US
Practice Address - Phone:949-707-2740
Practice Address - Fax:949-421-1194
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8335T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT79342Medicare UPIN