Basic Information
| Provider Information | |||||||||
| NPI: | 1811912769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKAKUWA | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 CHESTNUT ST | ||||||||
| Address2: | 14TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551175 | ||||||||
| FaxNumber: | 2159552420 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323000 | ||||||||
| FaxNumber: | 6512321187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 61761 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD421356 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0062499 | 05 | NJ | MEDICAID | 101228458 | 05 | PA | MEDICAID |