Provider Demographics
NPI:1740671254
Name:ENORU, SOSTANIE TAKOTA (MD)
Entity type:Individual
Prefix:DR
First Name:SOSTANIE
Middle Name:TAKOTA
Last Name:ENORU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SOSTANIE
Other - Middle Name:
Other - Last Name:TAKOTA ENORU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-0363
Mailing Address - Country:US
Mailing Address - Phone:573-636-0635
Mailing Address - Fax:
Practice Address - Street 1:3501 W TRUMAN BLVD # A
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0514
Practice Address - Country:US
Practice Address - Phone:573-636-0635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292675207R00000X, 207RC0000X, 208M00000X, 390200000X
MO2022031212207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program