Provider Demographics
NPI:1215961735
Name:TAKAHASHI, STEFANI REIKO (MD)
Entity type:Individual
Prefix:
First Name:STEFANI
Middle Name:REIKO
Last Name:TAKAHASHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEFANI
Other - Middle Name:REIKO
Other - Last Name:TOMONO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-6200
Mailing Address - Fax:
Practice Address - Street 1:1450 SAN PABLO ST STE 2000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5331
Practice Address - Country:US
Practice Address - Phone:323-442-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55242207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A552420OtherMEDI-CAL PPIN #
CAWA55242BMedicare PIN
CA00A552420OtherMEDI-CAL PPIN #