Provider Demographics
NPI:1073697991
Name:TAKLA, MEDHAT WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MEDHAT
Middle Name:WILLIAM
Last Name:TAKLA
Suffix:
Gender:M
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 230
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501122208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1073697991Medicaid
NC1073697991Medicaid
G18023Medicare PIN
NC2218508AMedicare PIN
NC8981428Medicare PIN