Provider Demographics
NPI:1104612399
Name:KOTAO, TAKUMI (RDN)
Entity type:Individual
Prefix:MS
First Name:TAKUMI
Middle Name:
Last Name:KOTAO
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3544 34TH ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1977
Mailing Address - Country:US
Mailing Address - Phone:347-879-2091
Mailing Address - Fax:347-879-2091
Practice Address - Street 1:462 1ST AVE RM 4018
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9196
Practice Address - Country:US
Practice Address - Phone:347-879-2091
Practice Address - Fax:347-879-2091
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86085367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered