Provider Demographics
NPI:1609807445
Name:TAKLE, LEIV M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LEIV
Middle Name:M
Last Name:TAKLE
Suffix:JR
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 1:646 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-228-3836
Mailing Address - Fax:770-412-1733
Practice Address - Street 1:646 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-228-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057850207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA180697446CMedicaid
GA18BDGSQMedicare PIN
GAI54682001Medicare UPIN