Provider Demographics
NPI:1124013057
Name:TAKETA, JOHN GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GLENN
Last Name:TAKETA
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 1:5011 SHORELINE WAY
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-2842
Mailing Address - Country:US
Mailing Address - Phone:805-760-4662
Mailing Address - Fax:
Practice Address - Street 1:5011 SHORELINE WAY
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035
Practice Address - Country:US
Practice Address - Phone:805-760-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29937207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G299370Medicare ID - Type Unspecified
A44228Medicare UPIN