Provider Demographics
NPI:1669579660
Name:TANISAWA, KEN YOSHIO (OD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:YOSHIO
Last Name:TANISAWA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 BURLINGAME AVENUE
Mailing Address - Street 2:SUITE F
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-4119
Mailing Address - Country:US
Mailing Address - Phone:650-342-7715
Mailing Address - Fax:650-342-8182
Practice Address - Street 1:1419 BURLINGAME AVENUE
Practice Address - Street 2:SUITE F
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4119
Practice Address - Country:US
Practice Address - Phone:650-342-7715
Practice Address - Fax:650-342-8182
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5604TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist