Provider Demographics
NPI:1568901379
Name:TAKITSU, SHUNICHI
Entity Type:Individual
Prefix:
First Name:SHUNICHI
Middle Name:
Last Name:TAKITSU
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 1:920 18 1/2 ST S
Mailing Address - Street 2:APT. 1
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3194
Mailing Address - Country:US
Mailing Address - Phone:701-541-3826
Mailing Address - Fax:
Practice Address - Street 1:920 18 1/2 ST S
Practice Address - Street 2:APT. 1
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3194
Practice Address - Country:US
Practice Address - Phone:701-541-3826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program