Provider Demographics
NPI:1225039985
Name:TAKACS-DILORENZO, EVA (MD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:TAKACS-DILORENZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 LAKESHORE DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558
Mailing Address - Country:US
Mailing Address - Phone:912-673-1771
Mailing Address - Fax:912-673-1811
Practice Address - Street 1:3340 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5250
Practice Address - Country:US
Practice Address - Phone:352-589-6005
Practice Address - Fax:352-589-6012
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048859207V00000X
FLME124211207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00869393AMedicaid
GA00869393AMedicaid
16BDTLCMedicare ID - Type Unspecified