Provider Demographics
NPI:1528158953
Name:TAK, ANDREW J (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:TAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4578
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617
Mailing Address - Country:US
Mailing Address - Phone:916-646-4583
Mailing Address - Fax:916-646-4056
Practice Address - Street 1:1111 EXPOSITION BLVD
Practice Address - Street 2:BLDG 400A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4314
Practice Address - Country:US
Practice Address - Phone:916-646-4583
Practice Address - Fax:916-646-4056
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG78315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G783150Medicaid
CA00G783150Medicaid
CAG05157Medicare UPIN