Provider Demographics
NPI:1629243837
Name:TAKESITA, KEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:TAKESITA
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 1:4500 BROCKTON AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4027
Mailing Address - Country:US
Mailing Address - Phone:626-396-1105
Mailing Address - Fax:
Practice Address - Street 1:4500 BROCKTON AVE STE 301
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4027
Practice Address - Country:US
Practice Address - Phone:951-276-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84860208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology