Provider Demographics
NPI:1134294309
Name:TAKACH, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:TAKACH
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 1:12 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3984
Mailing Address - Country:US
Mailing Address - Phone:207-945-4474
Mailing Address - Fax:
Practice Address - Street 1:12 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-945-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME006005207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86739Medicare UPIN
ME132950Medicare ID - Type Unspecified