MEDICARE: ROGER Y TAKLA M.D. INC.

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	208000000X	Pediatrics Physician	A43079	CA
2	208000000X	Pediatrics Physician	A29866	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0024690	OTHER	CA	CHDP PROVIDER

General Provider Information

NPI Number	:	1275608895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGER Y TAKLA M.D. INC.

Provider Business Mailing Address
First Line	:	1040 ELM AVE
Second Line	:	SUITE 301
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3267
Country	:	US
Telephone Number	:	562-491-9001
Fax Number	:	562-491-9283

Provider Business Practice Location Address
First Line	:	1040 ELM AVE
Second Line	:	SUITE 301
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3267
Country	:	US
Telephone Number	:	562-491-9001
Fax Number	:	562-491-9283

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROGER Y. TAKLA
Credential	:	M.D.
Telephone Number	:	562-491-9001

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	10/29/2012

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