Provider Demographics
NPI:1700972452
Name:TANAKA, CLIFFORD TERUO (MD)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:TERUO
Last Name:TANAKA
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 1:46-001 KAMEHAMEHA HIGHWAY
Mailing Address - Street 2:SUITE 312
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744
Mailing Address - Country:US
Mailing Address - Phone:808-247-2255
Mailing Address - Fax:808-247-7642
Practice Address - Street 1:46-001 KAMEHAMEHA HIGHWAY
Practice Address - Street 2:SUITE 312
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744
Practice Address - Country:US
Practice Address - Phone:808-247-2255
Practice Address - Fax:808-247-7642
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI5220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0021335OtherBLUE CROSS/SHIELD
HI01939201Medicaid
HIH0000BDMGSMedicare ID - Type Unspecified
HI00A0021335OtherBLUE CROSS/SHIELD