Healthcare Provider Details

I. General information

NPI: 1699327007
Provider Name (Legal Business Name): TAKAHISA MIKAMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 855-644-6387
  • Fax:
Mailing address:
  • Phone: 855-644-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1013130
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: