Healthcare Provider Details

I. General information

NPI: 1518808906
Provider Name (Legal Business Name): EDMUND TAMAS TAKATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S MAIN ST STE 201
MIDDLETOWN CT
06457-3649
US

IV. Provider business mailing address

90 S MAIN ST STE 201
MIDDLETOWN CT
06457-3649
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNA
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: