Provider Demographics
NPI:1619931060
Name:TAKALKAR, AMOL MADAN (MD)
Entity Type:Individual
Prefix:
First Name:AMOL
Middle Name:MADAN
Last Name:TAKALKAR
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 1:9303 SHENANDOAH CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3743
Mailing Address - Country:US
Mailing Address - Phone:318-795-0775
Mailing Address - Fax:
Practice Address - Street 1:1505 KINGS HWY
Practice Address - Street 2:PET IMAGING CENTER, BRF
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200309207UN0903X, 207U00000X, 207UN0901X, 207UN0902X
GA85681207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1626554Medicaid
4J744F600Medicare ID - Type Unspecified
LA1626554Medicaid