Healthcare Provider Details

I. General information

NPI: 1740671254
Provider Name (Legal Business Name): SOSTANIE TAKOTA ENORU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SOSTANIE TAKOTA ENORU M.D.

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W TRUMAN BLVD # A
JEFFERSON CITY MO
65109-0514
US

IV. Provider business mailing address

PO BOX 363
JEFFERSON CITY MO
65102-0363
US

V. Phone/Fax

Practice location:
  • Phone: 573-636-0635
  • Fax:
Mailing address:
  • Phone: 573-636-0635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2022031212
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2022031212
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: