MEDICARE: DR. STACY MAYUMI TAKETA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	003611	WA

General Provider Information

NPI Number	:	1235265547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY MAYUMI TAKETA O.D.

Provider Business Mailing Address
First Line	:	5101 25TH AVE NE STE 10
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-3225
Country	:	US
Telephone Number	:	206-432-9051
Fax Number	:	206-432-9264

Provider Business Practice Location Address
First Line	:	5101 25TH AVE NE STE 10
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-3225
Country	:	US
Telephone Number	:	206-432-9051
Fax Number	:	206-432-9264

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	10/14/2011

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