Provider Demographics
NPI:1275544389
Name:TAKEKUMA, HIROMI (DO)
Entity Type:Individual
Prefix:
First Name:HIROMI
Middle Name:
Last Name:TAKEKUMA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 BACON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2050
Mailing Address - Country:US
Mailing Address - Phone:925-676-2942
Mailing Address - Fax:925-676-7108
Practice Address - Street 1:2299 BACON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2050
Practice Address - Country:US
Practice Address - Phone:925-676-2942
Practice Address - Fax:925-676-7108
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6021207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A60211Medicaid
110118234OtherRR MEDICARE ID NUMBER
CAGR0064710Medicaid
CAZZZ00582ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER
110118234OtherRR MEDICARE ID NUMBER
12940Medicare UPIN