Provider Demographics
NPI:1003213935
Name:TAKO, THEOPHILUS
Entity Type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:
Last Name:TAKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1616
Mailing Address - Country:US
Mailing Address - Phone:202-723-3060
Mailing Address - Fax:202-723-3065
Practice Address - Street 1:7600 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1616
Practice Address - Country:US
Practice Address - Phone:202-723-3060
Practice Address - Fax:202-723-3065
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1029696163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse