Provider Demographics
NPI:1740603018
Name:TAKEUCHI, KOH (MD)
Entity Type:Individual
Prefix:DR
First Name:KOH
Middle Name:
Last Name:TAKEUCHI
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 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 HEART DR
Practice Address - Street 2:EAST CAROLINA HEART INSTITUTE AT ECU
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8944
Practice Address - Country:US
Practice Address - Phone:252-744-4400
Practice Address - Fax:252-744-3987
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA99-7946-99174400000X
NC2014-00071208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAC1220007-KT869Medicaid
NC1847SOtherBCBS NC
NC1740603018Medicaid
NCNCH169AMedicare PIN