Provider Demographics
NPI:1801884382
Name:TAKATA, THEODORE SUNAO (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:SUNAO
Last Name:TAKATA
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 1:1300 W TERRELL AVE
Mailing Address - Street 2:#500
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2800
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:817-252-5060
Practice Address - Street 1:1300 W TERRELL AVE
Practice Address - Street 2:#500
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2800
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:817-252-5060
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8508207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039267205Medicaid
TX039267203Medicaid
TXP00226814OtherRAIL ROAD MEDICARE
TX8M6142OtherBLUE CROSS
TXP00226814OtherRAIL ROAD MEDICARE
TX039267203Medicaid
TXTXB115217Medicare PIN
TX8744B0Medicare PIN