Healthcare Provider Details

I. General information

NPI: 1275608895
Provider Name (Legal Business Name): ROGER Y TAKLA M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 ELM AVE SUITE 301
LONG BEACH CA
90813-3267
US

IV. Provider business mailing address

1040 ELM AVE SUITE 301
LONG BEACH CA
90813-3267
US

V. Phone/Fax

Practice location:
  • Phone: 562-491-9001
  • Fax: 562-491-9283
Mailing address:
  • Phone: 562-491-9001
  • Fax: 562-491-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA43079
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA29866
License Number StateCA

VIII. Authorized Official

Name: DR. ROGER Y. TAKLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 562-491-9001