Basic Information
| Provider Information | |||||||||
| NPI: | 1609957802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANAKA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62053 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968392053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087359093 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1965 JUDD HILLSIDE RD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968222007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087359093 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD4431 | HI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01213201 | 05 | HI | MEDICAID |