Provider Demographics
NPI:1679641427
Name:TANAKA, LAURENCE K (MD)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:K
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 1:4060 FOURTH AVENUE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-298-9931
Mailing Address - Fax:619-298-3613
Practice Address - Street 1:4060 FOURTH AVENUE
Practice Address - Street 2:SUITE 330
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-298-9931
Practice Address - Fax:619-298-3613
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34455208600000X
LA011646208600000X
HIMD2833208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9815915Medicaid
A35626Medicare UPIN
CA9815915Medicaid