Provider Demographics
NPI:1447229901
Name:TAKACS, ELIZABETH BROGHAMMER (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROGHAMMER
Last Name:TAKACS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:LUCILLE
Other - Last Name:BROGHAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 S CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2926
Mailing Address - Country:US
Mailing Address - Phone:641-494-5280
Mailing Address - Fax:
Practice Address - Street 1:250 S CRESCENT DR
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2926
Practice Address - Country:US
Practice Address - Phone:641-494-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36562208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0499848Medicaid
IA24320OtherWELLMARK BCBS
TX158388201Medicaid
H83558Medicare UPIN
IAI17771Medicare PIN
8A6752Medicare ID - Type Unspecified
IA0499848Medicaid