Provider Demographics
NPI:1114911807
Name:TAKI, HASSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:
Last Name:TAKI
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 1:4424 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6917
Mailing Address - Country:US
Mailing Address - Phone:260-483-4433
Mailing Address - Fax:260-483-4223
Practice Address - Street 1:4424 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-483-4433
Practice Address - Fax:260-483-4223
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1924OtherPHYSCIANS HEALTH PLAN
IN3000054923Medicaid
1659549475OtherGROUP NPI
IN000000091432OtherBLUE CROSS/BLUE SHIELD
IN669280Medicare PIN
1659549475OtherGROUP NPI
IN0758179Medicare PIN