Provider Demographics
NPI:1487621801
Name:HATANAKA, ROBERT TADASHI (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TADASHI
Last Name:HATANAKA
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 1:1101 N PACIFIC AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202
Mailing Address - Country:US
Mailing Address - Phone:818-552-5000
Mailing Address - Fax:818-552-2959
Practice Address - Street 1:1101 N PACIFIC AVE
Practice Address - Street 2:STE 104
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202
Practice Address - Country:US
Practice Address - Phone:818-552-5000
Practice Address - Fax:818-552-2959
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E38140Medicaid
CAE3814CMedicare ID - Type Unspecified
CA000E38140Medicaid