1356341002 NPI number — DR. RUSSELL G TACATA M.D.

Table of content: DR. RUSSELL G TACATA M.D. (NPI 1356341002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356341002 NPI number — DR. RUSSELL G TACATA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TACATA
Provider First Name:
RUSSELL
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356341002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1619 LILIHA STREET
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96817-3152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-531-5454
Provider Business Mailing Address Fax Number:
808-531-5451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 LILIHA STREET
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96817-3152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-531-5454
Provider Business Practice Location Address Fax Number:
808-531-5451
Provider Enumeration Date:
07/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  9570 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07892401 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020779-5 . This is a "HMSA" identifier . This identifiers is of the category "OTHER".




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