Provider Demographics
NPI:1053738021
Name:TAKEDA, ALISA (DO)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:TAKEDA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4220
Mailing Address - Country:US
Mailing Address - Phone:510-986-6800
Mailing Address - Fax:510-986-6896
Practice Address - Street 1:818 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4220
Practice Address - Country:US
Practice Address - Phone:510-986-6800
Practice Address - Fax:510-986-6896
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A14368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program