Provider Demographics
NPI:1811912769
Name:TAKAKUWA, KEVIN M (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:TAKAKUWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:615 CHESTNUT ST
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4404
Mailing Address - Country:US
Mailing Address - Phone:215-955-1175
Mailing Address - Fax:215-955-2420
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:651-232-1187
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN61761207P00000X
PAMD421356207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0062499Medicaid
PA101228458Medicaid
NJ0062499Medicaid