Basic Information
| Provider Information | |||||||||
| NPI: | 1447604368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKI | ||||||||
| FirstName: | MOHAMED | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537920001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082638175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137451892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2016 | ||||||||
| LastUpdateDate: | 07/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 71135-20 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.