Provider Demographics
NPI:1164685715
Name:TAKAGISHI, TROY K (MD)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:K
Last Name:TAKAGISHI
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 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-272-5100
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3991 DUTCHMANS LN STE 211
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4723
Practice Address - Country:US
Practice Address - Phone:502-899-6061
Practice Address - Fax:502-899-6127
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.122220207R00000X, 208000000X
KYTP865207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100170030Medicaid
IN201033700Medicaid
KYP00992208OtherRAILROAD MEDICARE
KY50033886OtherPASSPORT- NORTON RHEUMATOLOGY SPECIALISTS
KYK008530Medicare PIN