Basic Information
| Provider Information | |||||||||
| NPI: | 1437260825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKEMOTO | ||||||||
| FirstName: | FERN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6555 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G71709 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 90026157 | 01 | CA | PACIFICARE | OTHER | 000810342982 | 01 | CA | PHCS | OTHER | 00G717090 | 05 | CA | MEDICAID | 016914 | 01 | CA | HEALTH NET | OTHER | 3822049 | 01 | CA | CIGNA | OTHER | 4509750 | 01 | CA | AETNA | OTHER | G71709 | 01 | CA | BLUE CROSS | OTHER | 18634 | 01 | CA | INTERPLAN | OTHER | 1062717 | 01 | CA | FIRST HEALTH | OTHER | MCMG126500 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER | 1089896 | 01 | CA | GREAT WEST | OTHER | 1268025 | 01 | CA | UNITED HEALTHCARE | OTHER |