Provider Demographics
NPI:1649413139
Name:VICTOR N TAKLA MD LLC
Entity Type:Organization
Organization Name:VICTOR N TAKLA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:N
Authorized Official - Last Name:TAKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-667-6511
Mailing Address - Street 1:4136 NW THUNDER CREST RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8028
Mailing Address - Country:US
Mailing Address - Phone:208-667-6511
Mailing Address - Fax:208-666-1642
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:208-667-6511
Practice Address - Fax:208-666-1642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty