Provider Demographics
NPI:1437268018
Name:TAKESUE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TAKESUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15390 CALLE DESPENSERO
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-3309
Mailing Address - Country:US
Mailing Address - Phone:626-571-7753
Mailing Address - Fax:
Practice Address - Street 1:6801 PARK TER FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-665-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27238OtherLICENSE #