Provider Demographics
NPI:1245484690
Name:TAKACH, THOMAS J (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:TAKACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6540 BELLOWS LN # 110
Mailing Address - Street 2:FAVROT HALL
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2802
Mailing Address - Country:US
Mailing Address - Phone:980-322-3015
Mailing Address - Fax:
Practice Address - Street 1:1697 LIBERTY AVE
Practice Address - Street 2:CARDIOTHORACIC, VASCULAR, AND ENDOVASCULAR SURGERY
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3517
Practice Address - Country:US
Practice Address - Phone:980-322-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301402346208600000X
CAA51118208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery