Provider Demographics
NPI:1770646812
Name:TANAKA, THOMAS JIN (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JIN
Last Name:TANAKA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 S VINEYARD AVE
Mailing Address - Street 2:BLDG. D
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7925
Mailing Address - Country:US
Mailing Address - Phone:714-832-7212
Mailing Address - Fax:714-832-0554
Practice Address - Street 1:2295 S VINEYARD AVE
Practice Address - Street 2:BLDG. D
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7925
Practice Address - Country:US
Practice Address - Phone:909-724-5052
Practice Address - Fax:714-832-0554
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3648213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E36480Medicaid
WE3648AMedicare PIN
E3648Medicare PIN
E3648AMedicare PIN
CA000E36480Medicaid
T95864Medicare UPIN