Provider Demographics
NPI:1790837490
Name:DENNISTON, BARON TAKAYUKI (MD)
Entity Type:Individual
Prefix:DR
First Name:BARON
Middle Name:TAKAYUKI
Last Name:DENNISTON
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 1:150 E 8TH ST
Mailing Address - Street 2:1ST FLR.
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1269
Mailing Address - Country:US
Mailing Address - Phone:814-456-1863
Mailing Address - Fax:814-456-0864
Practice Address - Street 1:150 E 8TH ST
Practice Address - Street 2:1ST..FLR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1269
Practice Address - Country:US
Practice Address - Phone:814-456-1863
Practice Address - Fax:814-456-0864
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044363L2084P0804X
PAMD044333L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE96834Medicare UPIN
PA390198Medicare ID - Type Unspecified