1619931060 NPI number — AMOL MADAN TAKALKAR M.D.

Table of content: AMOL MADAN TAKALKAR M.D. (NPI 1619931060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619931060 NPI number — AMOL MADAN TAKALKAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAKALKAR
Provider First Name:
AMOL
Provider Middle Name:
MADAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619931060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9303 SHENANDOAH CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71115-3743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-795-0775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 KINGS HWY
Provider Second Line Business Practice Location Address:
PET IMAGING CENTER, BRF
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71103-4228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-675-4050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207UN0903X , with the licence number:  MD.200309 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207U00000X , with the licence number: MD.200309 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207U00000X , with the licence number: 85681 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: MD.200309 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0902X , with the licence number: MD.200309 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1626554 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".