Healthcare Provider Details

I. General information

NPI: 1699751495
Provider Name (Legal Business Name): TED SATOSHI TANAKA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11362 SAN PABLO AVE
EL CERRITO CA
94530-2135
US

IV. Provider business mailing address

11362 SAN PABLO AVE
EL CERRITO CA
94530-2135
US

V. Phone/Fax

Practice location:
  • Phone: 510-233-4443
  • Fax: 510-233-1337
Mailing address:
  • Phone: 510-233-4443
  • Fax: 510-233-1337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE3450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: