Healthcare Provider Details

I. General information

NPI: 1457428328
Provider Name (Legal Business Name): TADASHI T. FUNAHASHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 11/29/2021
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N LAKEVIEW AVE
ANAHEIM CA
92807-3028
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-2800
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberG61301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: