Provider Demographics
NPI:1306046065
Name:KIDO, TAKAAKI (MD)
Entity Type:Individual
Prefix:
First Name:TAKAAKI
Middle Name:
Last Name:KIDO
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 1:2711 S. ROUSE STE. F
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-232-9000
Mailing Address - Fax:620-232-9005
Practice Address - Street 1:2711 S. ROUSE STE. F
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-232-9000
Practice Address - Fax:620-232-9005
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32899208600000X
KS32899208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200568970AMedicaid
KS1176Medicare PIN
KSKA1307Medicare PIN