Provider Demographics
NPI:1639113269
Name:TAKETA, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:TAKETA
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:DEPT LA 21555
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1555
Mailing Address - Country:US
Mailing Address - Phone:949-764-5570
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:16100 SAND CANYON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3716
Practice Address - Country:US
Practice Address - Phone:949-417-1100
Practice Address - Fax:949-417-1165
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23741207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A237410OtherBLUE SHIELD
CA00A237410Medicaid
CA00A237410Medicaid
CAWA23741CMedicare PIN
CAWA23741AMedicare PIN
CAWA23741HMedicare PIN
CA00A237410OtherBLUE SHIELD
A23662Medicare UPIN