Provider Demographics
NPI:1184835811
Name:WADA, TAKASHI MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:TAKASHI
Middle Name:MICHAEL
Last Name:WADA
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 1:3233 TERZILLA PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-4824
Mailing Address - Country:US
Mailing Address - Phone:323-559-0490
Mailing Address - Fax:
Practice Address - Street 1:1845 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1620
Practice Address - Country:US
Practice Address - Phone:626-744-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA56010OtherLICENSE NUMBER