Provider Demographics
NPI:1568919298
Name:TAKEMOTO, KENT (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:TAKEMOTO
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 1:4133 REDWOOD AVE UNIT 1023
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5630
Mailing Address - Country:US
Mailing Address - Phone:813-965-1859
Mailing Address - Fax:
Practice Address - Street 1:4133 REDWOOD AVE UNIT 1023
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5630
Practice Address - Country:US
Practice Address - Phone:813-965-1859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69163208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice