Provider Demographics
NPI:1275181554
Name:KAKO, TAVONNA DENISE (MD)
Entity type:Individual
Prefix:
First Name:TAVONNA
Middle Name:DENISE
Last Name:KAKO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:TAVONNA
Other - Middle Name:D
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 S GREENLEAF CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6002 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-5614
Practice Address - Country:US
Practice Address - Phone:317-880-6002
Practice Address - Fax:317-880-0417
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01093997A207VX0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104256339OtherANTHEM PTAN
IN300093177Medicaid