Provider Demographics
NPI:1790373363
Name:TAKEDA, ALEX (OD)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:TAKEDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-3117
Mailing Address - Country:US
Mailing Address - Phone:916-448-6622
Mailing Address - Fax:916-448-6686
Practice Address - Street 1:915 21ST ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-3117
Practice Address - Country:US
Practice Address - Phone:916-448-6622
Practice Address - Fax:916-448-6686
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist