Provider Demographics
NPI:1063410827
Name:TAKO, MODESTA MAKEH (MD)
Entity type:Individual
Prefix:DR
First Name:MODESTA
Middle Name:MAKEH
Last Name:TAKO
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Gender:F
Credentials:MD
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Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:404-691-2382
Practice Address - Street 1:1175 CASCADE PKWY SW
Practice Address - Street 2:KAISER PERMANENTE CASCADE MEMORIAL CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-3090
Practice Address - Country:US
Practice Address - Phone:404-505-4006
Practice Address - Fax:404-691-2382
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-01-10
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Provider Licenses
StateLicense IDTaxonomies
NY246485207Q00000X
GA073157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02957371Medicaid
NY021823K511Medicare PIN
MO209047414Medicaid
MOL20214Medicare UPIN