Provider Demographics
NPI:1760514137
Name:MINAMI, ROLAND TAKASHI (MD)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:TAKASHI
Last Name:MINAMI
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 1:1240
Mailing Address - Street 2:SOUTH ELISEO DR 102
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904
Mailing Address - Country:US
Mailing Address - Phone:415-461-1240
Mailing Address - Fax:415-461-4638
Practice Address - Street 1:1240
Practice Address - Street 2:SOUTH ELISEO DR 102
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-461-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21902208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A41419Medicare UPIN
00G21902Medicare ID - Type Unspecified