Provider Demographics
NPI:1942374111
Name:TAKAGI, BRIAN K (MD, PLLC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
Last Name:TAKAGI
Suffix:
Gender:M
Credentials:MD, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21906 76TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026
Mailing Address - Country:US
Mailing Address - Phone:425-774-2620
Mailing Address - Fax:425-774-2607
Practice Address - Street 1:21906 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026
Practice Address - Country:US
Practice Address - Phone:425-774-2620
Practice Address - Fax:425-774-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035675174400000X
WAMD35675207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF70963Medicare UPIN