Provider Demographics
NPI:1518467984
Name:TAKEGOSHI, YASUO
Entity Type:Individual
Prefix:
First Name:YASUO
Middle Name:
Last Name:TAKEGOSHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 DAWN RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5048
Mailing Address - Country:US
Mailing Address - Phone:916-989-9206
Mailing Address - Fax:
Practice Address - Street 1:1935 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6637
Practice Address - Country:US
Practice Address - Phone:916-455-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA265860208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366456170OtherDIABETES