Provider Demographics
NPI:1639257108
Name:TANAKA, GLEN A (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:TANAKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 S KING ST STE 203
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-2131
Mailing Address - Country:US
Mailing Address - Phone:808-955-2015
Mailing Address - Fax:808-949-4915
Practice Address - Street 1:1831 S KING ST STE 203
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-2131
Practice Address - Country:US
Practice Address - Phone:808-955-2015
Practice Address - Fax:808-949-4915
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI279152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02369301Medicaid
HIHMAMedicare UPIN
HIUHAMedicare UPIN
HIALOHA CAREMedicare UPIN
HIHMAAMedicare UPIN
HI02369301Medicaid
HI0000PGBMXMedicare ID - Type UnspecifiedMEDICARE