Basic Information
| Provider Information | |||||||||
| NPI: | 1225039985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKACS-DILORENZO | ||||||||
| FirstName: | EVA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 LAKESHORE DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126731771 | ||||||||
| FaxNumber: | 9126731811 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 LAKESHORE DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315583842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126731771 | ||||||||
| FaxNumber: | 9126731811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 048859 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00869393A | 05 | GA | MEDICAID |