Provider Demographics
NPI:1639436199
Name:TANAKA, SHOICHIRO ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOICHIRO
Middle Name:ALBERTO
Last Name:TANAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:MSC 8238-43-1150
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7388
Mailing Address - Fax:314-367-0225
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:DIV SURG PLASTICS, STE 101
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-433-6131
Practice Address - Fax:618-433-6128
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036155527208600000X, 208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000952542Medicaid