Provider Demographics
NPI:1932251873
Name:TAKEGAMI, KEN T (MD)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:T
Last Name:TAKEGAMI
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 1:100 WILLIAM NORTHERN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-455-7400
Mailing Address - Fax:931-455-6344
Practice Address - Street 1:100 WILLIAM NORTHERN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-455-7400
Practice Address - Fax:931-455-6344
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD021099207N00000X
TNMD0000021099207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3063983OtherBCBS OF TENNESSEE
TN3075822OtherMEDICARE
TN3373903Medicaid
TN3075822OtherMEDICARE
TN3373903Medicare ID - Type UnspecifiedGP NUMBER