Provider Demographics
NPI:1972904498
Name:TANAKA, MOMO
Entity Type:Individual
Prefix:DR
First Name:MOMO
Middle Name:
Last Name:TANAKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 FAIRFIELD AVE APT A2
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-2143
Mailing Address - Country:US
Mailing Address - Phone:919-607-3642
Mailing Address - Fax:
Practice Address - Street 1:123 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-1917
Practice Address - Country:US
Practice Address - Phone:203-854-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003963174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian