Provider Demographics
NPI:1629110036
Name:HIRATA, TAKASHI (MD)
Entity Type:Individual
Prefix:
First Name:TAKASHI
Middle Name:
Last Name:HIRATA
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-998-9060
Mailing Address - Fax:336-998-9061
Practice Address - Street 1:121 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-6651
Practice Address - Country:US
Practice Address - Phone:336-998-9060
Practice Address - Fax:336-998-9061
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00456679OtherRAILROAD MEDICARE
NC5907256Medicaid
NC5907256Medicaid
NC340014Medicare Oscar/Certification