Provider Demographics
NPI:1902105646
Name:TATSUMI, KANAYO (MD)
Entity Type:Individual
Prefix:
First Name:KANAYO
Middle Name:
Last Name:TATSUMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2718
Mailing Address - Country:US
Mailing Address - Phone:314-622-4971
Mailing Address - Fax:
Practice Address - Street 1:1300 CLARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2718
Practice Address - Country:US
Practice Address - Phone:314-622-4971
Practice Address - Fax:314-977-7615
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278417207ZF0201X, 207ZP0102X
MO2019024496207ZP0102X, 207ZF0201X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program