Healthcare Provider Details

I. General information

NPI: 1831146513
Provider Name (Legal Business Name): TADASHI NITASAKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13491 MOUND AVE
GLEN ELLEN CA
95442-1054
US

IV. Provider business mailing address

PO BOX 1054
GLEN ELLEN CA
95442-1054
US

V. Phone/Fax

Practice location:
  • Phone: 170-799-6862
  • Fax:
Mailing address:
  • Phone: 170-799-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG63573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: