NPIMap

Individual provider Active NPI

Guillermo Javier Tanaka, M. D.

  • Diagnostic Radiology Physician
  • Jackson, MS
National Provider Identifier
1124033055
Registry record updated Nov 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
16799 Issued in MS
Practice address
969 Lakeland Dr
Jackson, MS 39216-4606
Phone
(877) 406-2916
Fax
(601) 682-7909
NPI assigned
Jul 29, 2006
Last updated
Nov 8, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 16799 MS Primary
Diagnostic Radiology Physician 2085R0202X 022779 LA

Addresses

Primary practice location

969 Lakeland Dr
Jackson, MS 39216-4606

Mailing address

PO Box 55769
Jackson, MS 39296-5769
Phone (601) 200-6162

Other practice location 1

433 Plaza St
Bogalusa, LA 70427-3729
Phone (985) 730-6803

Other identifiers 3

IdentifierTypeStateIssuer
1861428351OtherGROUP MEDICARE NPI
C00475OtherGROUP MEDICARE UPIN
00122175MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS, LA2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20061222000169 MS Practitioner - Interventional RadiologyPractitioner - Diagnostic Radiology 0749280782 Reassigns benefits to 1 organization
I20240130002025 LA Practitioner - Diagnostic Radiology 0749280782 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
Tulane University School of Medicine, 1995
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Regional Radiology, LLCGroup PAC ID 2860404811, 40 clinicians

Practice addresses (Care Compare)

1202 S Tyler St
Covington, LA 70433-2330
Phone (985) 898-4000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
022779LAMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Wash-St Tammany Reg Medical Center Current Accepting new patients
Our Lady of the Angels Hospital, Inc. CurrentSince Dec 11, 2023 Accepting new patients
Lakeland Radiologists P a Diagnostic Radiology CurrentSince Oct 1, 2001 Accepting new patients
Regional Radiology, LLC Diagnostic Radiology CurrentSince Feb 15, 2024 Accepting new patients
Washington St. Tammany Regional Medical Center Past Accepting new patients
Madison Imaging LLC Diagnostic Radiology PastSince Oct 31, 2006 Accepting new patients
St Dominic-Jackson Memorial Hospital Past Accepting new patients
St Tammany Parish Hospital Service District No 1 Past Accepting new patients
Lafayette Health Ventures, Inc Past Accepting new patients

Locations

5959 S Sherwood Forest Blvd
Baton Rouge, LA 70816
Phone (225) 526-0011

433 Plaza St
Bogalusa, LA 70427
Phone (985) 730-6700

1202 S Tyler St
Covington, LA 70433
Phone (985) 898-3743

16282 Highway 1085
Covington, LA 70433
Phone (985) 898-4140

82525 Highway 25
Folsom, LA 70437
Phone (985) 839-9895

1322 Elton Rd
Ste F
Jennings, LA 70546
Phone (337) 824-8868

409 W Pont des Mouton Rd
Lafayette, LA 70507

969 Lakeland Dr
Jackson, MS 39216
Phone (601) 200-4644

106 Highland Way
Ste 100
Madison, MS 39110
Phone (601) 200-8410

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154131200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1699401600000",
    "number": "1124033055",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 55769",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392965769",
            "telephone_number": "601-200-6162"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "969 LAKELAND DR",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164606",
            "telephone_number": "877-406-2916",
            "fax_number": "601-682-7909"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "433 Plaza St",
            "address_purpose": "LOCATION",
            "city": "Bogalusa",
            "state": "LA",
            "postal_code": "704273729",
            "country_code": "US",
            "telephone_number": "985-730-6803",
            "fax_number": "985-730-6806",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TANAKA",
        "first_name": "GUILLERMO",
        "middle_name": "JAVIER",
        "name_prefix": "Dr.",
        "credential": "M. D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-29",
        "last_updated": "2023-11-08",
        "certification_date": "2023-11-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "MS",
            "license": "16799",
            "primary": true
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "LA",
            "license": "022779",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE NPI",
            "identifier": "1861428351",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE UPIN",
            "identifier": "C00475",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00122175",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jackson, MS

Sources for this page

Verify at the official NPI Registry.