Healthcare Provider Details

I. General information

NPI: 1578660122
Provider Name (Legal Business Name): THOMAS J, TANAKA, DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 IRVINE BLVD SUITE H
TUSTIN CA
92780-3030
US

IV. Provider business mailing address

17400 IRVINE BLVD SUITE H
TUSTIN CA
92780-3030
US

V. Phone/Fax

Practice location:
  • Phone: 714-832-7212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3648
License Number StateCA

VIII. Authorized Official

Name: THOMAS TANAKA
Title or Position: OWNER
Credential:
Phone: 714-832-7212