Healthcare Provider Details

I. General information

NPI: 1790895803
Provider Name (Legal Business Name): TAKAHIRO OTSUKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST SUITE 3400
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2870
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA55960
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: