Provider Demographics
NPI:1841218872
Name:TAKUBO, TAMEJIRO JR (DO)
Entity Type:Individual
Prefix:DR
First Name:TAMEJIRO
Middle Name:
Last Name:TAKUBO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 KANAWHA AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1319
Mailing Address - Country:US
Mailing Address - Phone:304-400-4545
Mailing Address - Fax:304-400-4546
Practice Address - Street 1:4619 KANAWHA AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1319
Practice Address - Country:US
Practice Address - Phone:304-400-4545
Practice Address - Fax:304-400-4546
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1828207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH27187Medicare UPIN