Provider Demographics
NPI:1477642148
Name:TAKALA, GERALD M (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:M
Last Name:TAKALA
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 1:751 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1450
Mailing Address - Country:US
Mailing Address - Phone:906-884-4120
Mailing Address - Fax:906-884-2861
Practice Address - Street 1:751 S 7TH ST
Practice Address - Street 2:
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1450
Practice Address - Country:US
Practice Address - Phone:906-884-4120
Practice Address - Fax:906-884-2861
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00655327OtherRAILROAD MEDICARE
MI0M76190OtherMEDICARE GROUP
MI3520238Medicaid
MIMI1614OtherMEDICARE GROUP
MIMI1614001Medicare PIN
MIP00655327OtherRAILROAD MEDICARE
MI0M76190OtherMEDICARE GROUP