Provider Demographics
NPI:1346285962
Name:TAKATA, JAY H (PA)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:H
Last Name:TAKATA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:800-506-6895
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:12401 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1006
Practice Address - Country:US
Practice Address - Phone:562-698-0811
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15700Medicaid
CAP00282752OtherRAILROAD MEDICARE
CAP00282752OtherRAILROAD MEDICARE
CAPA15700Medicaid