Provider Demographics
NPI:1982759346
Name:TAKASHI WAKAMORE, MD
Entity Type:Organization
Organization Name:TAKASHI WAKAMORE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TAKASHI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKAMORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-592-8555
Mailing Address - Street 1:810 ABBOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-4151
Mailing Address - Country:US
Mailing Address - Phone:201-592-8555
Mailing Address - Fax:201-592-8501
Practice Address - Street 1:810 ABBOTT BLVD
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4151
Practice Address - Country:US
Practice Address - Phone:201-592-8555
Practice Address - Fax:201-592-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ521115Medicare ID - Type Unspecified