Provider Demographics
NPI:1447201074
Name:TAKLE, LEIV MUNLAUG (MD)
Entity Type:Individual
Prefix:DR
First Name:LEIV
Middle Name:MUNLAUG
Last Name:TAKLE
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 1:646 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224
Mailing Address - Country:US
Mailing Address - Phone:770-228-3836
Mailing Address - Fax:770-412-1733
Practice Address - Street 1:646 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:770-228-3836
Practice Address - Fax:770-412-1733
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15043207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000088877AMedicaid
0706580001OtherDMEPOS MEDICARE #
GA000088877AMedicaid
GA0706580001Medicare NSC