Basic Information
| Provider Information | |||||||||
| NPI: | 1770670556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATANABE | ||||||||
| FirstName: | TAKENORI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 ALHAMBRA AVE | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 ALHAMBRA AVE | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00046865 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 37772 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A107382 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 327749 | 05 | AZ | MEDICAID | BW8867460 | 01 | WA | DEA | OTHER |