Healthcare Provider Details

I. General information

NPI: 1194874578
Provider Name (Legal Business Name): KEN MARK TASHIRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W PERIMETER RD 79TH MDG MALCOLM GROW MEDICAL CENTER
ANDREWS AFB MD
20762-6601
US

IV. Provider business mailing address

9902 HOLMHURST RD
BETHESDA MD
20817-1618
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-4530
  • Fax:
Mailing address:
  • Phone: 301-448-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036188A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01036188A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: