Basic Information
| Provider Information | |||||||||
| NPI: | 1942573290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKEDA | ||||||||
| FirstName: | KOJI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27765 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100877765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123059576 | ||||||||
| FaxNumber: | 2123059480 | ||||||||
| Practice Location | |||||||||
| Address1: | 177 FORT WASHINGTON AVE | ||||||||
| Address2: | MHB 7GN-435 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123423892 | ||||||||
| FaxNumber: | 2123425262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2012 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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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 | 208G00000X | 267435 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 03529031 | 05 | NY | MEDICAID |