Provider Demographics
NPI:1457465882
Name:TAK, ABDUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:R
Last Name:TAK
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 1:3015 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1969
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:502-772-8984
Practice Address - Street 1:3015 WILSON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1969
Practice Address - Country:US
Practice Address - Phone:502-774-4401
Practice Address - Fax:502-772-8984
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64212236Medicaid
KY1048778Medicaid
KYD47522Medicare UPIN
KY0696005Medicare ID - Type Unspecified
KY1048778Medicaid