Provider Demographics
NPI:1922189471
Name:TAKAO, KEVIN (MPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TAKAO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6759 SIERRA CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2670
Mailing Address - Country:US
Mailing Address - Phone:925-803-0530
Mailing Address - Fax:925-803-2047
Practice Address - Street 1:6759 SIERRA CT
Practice Address - Street 2:SUITE A
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2670
Practice Address - Country:US
Practice Address - Phone:925-803-0530
Practice Address - Fax:925-803-2047
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32822174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21382ZMedicare ID - Type UnspecifiedMEDICARE