Basic Information
| Provider Information | |||||||||
| NPI: | 1326043738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANOUYE | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | TOSHIYUKI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18370 BURBANK BLVD | ||||||||
| Address2: | STE 601 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913562831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189965700 | ||||||||
| FaxNumber: | 8189961649 | ||||||||
| Practice Location | |||||||||
| Address1: | 18370 BURBANK BLVD | ||||||||
| Address2: | STE 601 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913562831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189965700 | ||||||||
| FaxNumber: | 8189961649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G50249 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | YYY40048Y | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | YYY40048Y | 05 | CA | MEDICAID | 95-3132732 | 01 | CA | BLUE CROSS OF CALIFORNIA | OTHER | WG50249D | 01 | CA | MEDICARE RENDERING NUMBER | OTHER | 110061982 | 01 | CA | RAILROAD RENDERING NUMBER | OTHER | T0796 | 01 | CA | RAILROAD GROUP NUMBER | OTHER |