Healthcare Provider Details

I. General information

NPI: 1629243837
Provider Name (Legal Business Name): KEN TAKESITA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 301
RIVERSIDE CA
92501-4027
US

IV. Provider business mailing address

4500 BROCKTON AVE STE 301
RIVERSIDE CA
92501-4027
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-4505
  • Fax:
Mailing address:
  • Phone: 626-396-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA84860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: