Healthcare Provider Details

I. General information

NPI: 1104612399
Provider Name (Legal Business Name): TAKUMI KOTAO RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE RM 4018
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

3544 34TH ST APT 4D
ASTORIA NY
11106-1977
US

V. Phone/Fax

Practice location:
  • Phone: 347-879-2091
  • Fax: 347-879-2091
Mailing address:
  • Phone: 347-879-2091
  • Fax: 347-879-2091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86085367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: