Provider Demographics
NPI:1699751495
Name:TANAKA, TED SATOSHI (DPM)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:SATOSHI
Last Name:TANAKA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11362 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2135
Mailing Address - Country:US
Mailing Address - Phone:510-233-4443
Mailing Address - Fax:510-233-1337
Practice Address - Street 1:11362 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2135
Practice Address - Country:US
Practice Address - Phone:510-233-4443
Practice Address - Fax:510-233-1337
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3450213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000E34500OtherMEDICARE
CAT11965Medicare UPIN