Provider Demographics
NPI:1437260825
Name:TAKEMOTO, FERN S (MD)
Entity Type:Individual
Prefix:
First Name:FERN
Middle Name:S
Last Name:TAKEMOTO
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-733-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71709208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90026157OtherPACIFICARE
CA000810342982OtherPHCS
CA00G717090Medicaid
CA016914OtherHEALTH NET
CA3822049OtherCIGNA
CA4509750OtherAETNA
CAG71709OtherBLUE CROSS
CA18634OtherINTERPLAN
CA1062717OtherFIRST HEALTH
CAMCMG126500OtherWESTERN HEALTH ADVANTAGE
CA1089896OtherGREAT WEST
CA1268025OtherUNITED HEALTHCARE
CA1062717OtherFIRST HEALTH
CA4509750OtherAETNA