Provider Demographics
NPI:1164463907
Name:TAKAHASHI, BRUCE A (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:TAKAHASHI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:
Practice Address - Street 1:934 W HATCHER RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-3139
Practice Address - Country:US
Practice Address - Phone:602-344-6300
Practice Address - Fax:602-344-6301
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ349739Medicaid
AZ134141Medicare PIN
AZ23697Medicare PIN
G34698Medicare UPIN