Provider Demographics
NPI:1215921374
Name:TAKACS, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TAKACS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5909 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1470
Mailing Address - Country:US
Mailing Address - Phone:503-234-1531
Mailing Address - Fax:503-234-2367
Practice Address - Street 1:5909 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1470
Practice Address - Country:US
Practice Address - Phone:503-234-1531
Practice Address - Fax:503-234-2367
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15382207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075562Medicaid
OR048825002OtherBCBSO
OR075562Medicaid