Provider Demographics
NPI:1629140678
Name:ISLAS, JEFFREY TANAKA (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TANAKA
Last Name:ISLAS
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 1:701 EAST 28TH ST
Mailing Address - Street 2:#201
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806
Mailing Address - Country:US
Mailing Address - Phone:562-424-0421
Mailing Address - Fax:562-427-8005
Practice Address - Street 1:701 EAST 28TH ST
Practice Address - Street 2:#201
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-424-0421
Practice Address - Fax:562-427-8005
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69424208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079620Medicaid
CAGR0079620Medicaid
CAW13479Medicare ID - Type Unspecified