Healthcare Provider Details

I. General information

NPI: 1700442449
Provider Name (Legal Business Name): JOELLE TAKAHASHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST ARBOR DRIVE
SAN DIEGO CA
92103-8770
US

IV. Provider business mailing address

200 WEST ARBOR DRIVE, MC 8770
SAN DIEGO CA
92103-8770
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-5297
  • Fax:
Mailing address:
  • Phone: 619-543-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number13408613-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMDR-7696
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: