Individual
MR. KEN T TAKEGAMI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 WILLIAM NORTHERN BLVD, SUITE C, TULLAHOMA, TN 37388
(931) 455-7400
(931) 455-6344
Mailing address
100 WILLIAM NORTHERN BLVD, SUITE C, TULLAHOMA, TN 37388
(931) 455-7400
(931) 455-6344
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
MD021099
TN
207ND0101X
MOHS-Micrographic Surgery Physician
MD0000021099
TN
207ND0900X
Dermatopathology Physician
MD0000021099
TN
207NS0135X
Procedural Dermatology Physician
MD0000021099
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3063983
BCBS OF TENNESSEE
TN
01
—
3075822
MEDICARE
TN
05
—
3373903
—
TN
Enumeration date
01/18/2007
Last updated
12/04/2009
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