Provider Demographics
NPI:1164929568
Name:TAKEDA, HIRONOBU (DO)
Entity Type:Individual
Prefix:
First Name:HIRONOBU
Middle Name:
Last Name:TAKEDA
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 1:6043 PRESTLEY MILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2280
Mailing Address - Country:US
Mailing Address - Phone:770-941-8100
Mailing Address - Fax:
Practice Address - Street 1:6043 PRESTLEY MILL RD STE B
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2280
Practice Address - Country:US
Practice Address - Phone:770-941-8100
Practice Address - Fax:678-945-9331
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA93245207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program