Provider Demographics
NPI:1134225626
Name:TAKATA, GLENN SHIGEO (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:SHIGEO
Last Name:TAKATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1527
Mailing Address - Country:US
Mailing Address - Phone:323-669-2337
Mailing Address - Fax:323-644-8488
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2534
Practice Address - Fax:323-906-8003
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52851208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G528510Medicaid
CA00G528510Medicaid
CA00G528510Medicaid