Healthcare Provider Details

I. General information

NPI: 1174549968
Provider Name (Legal Business Name): PETER TAKACS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE SUITE 310
NORFOLK VA
23507-1914
US

IV. Provider business mailing address

PO BOX 936 EVMS MEDICAL GROUP
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-7979
  • Fax: 757-446-8907
Mailing address:
  • Phone: 757-446-7979
  • Fax: 757-446-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101055079
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number0101055079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: