Provider Demographics
NPI:1073947016
Name:TAKATA, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:TAKATA
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 1:120 SKOKIE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3050
Mailing Address - Country:US
Mailing Address - Phone:847-251-3330
Mailing Address - Fax:847-251-9580
Practice Address - Street 1:120 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3050
Practice Address - Country:US
Practice Address - Phone:847-251-3330
Practice Address - Fax:847-251-9580
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician