Basic Information
Provider Information | |||||||||
NPI: | 1417198490 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NAKAMOTO | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | TAKAMORI | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4500 13TH ST | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288653151 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4500 13TH ST | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288653151 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2009 | ||||||||
LastUpdateDate: | 03/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 22566 | MS | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD.203905 | LA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.