Provider Demographics
NPI:1275608895
Name:ROGER Y TAKLA M.D. INC.
Entity Type:Organization
Organization Name:ROGER Y TAKLA M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TAKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-491-9001
Mailing Address - Street 1:1040 ELM AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3267
Mailing Address - Country:US
Mailing Address - Phone:562-491-9001
Mailing Address - Fax:562-491-9283
Practice Address - Street 1:1040 ELM AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3267
Practice Address - Country:US
Practice Address - Phone:562-491-9001
Practice Address - Fax:562-491-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29866208000000X
CAA43079208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0024690OtherCHDP PROVIDER