Provider Demographics
NPI:1225142128
Name:SARDJONO, HERMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:
Last Name:SARDJONO
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 1:72 LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-8565
Mailing Address - Country:US
Mailing Address - Phone:626-821-5305
Mailing Address - Fax:626-821-0141
Practice Address - Street 1:72 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007
Practice Address - Country:US
Practice Address - Phone:626-821-5305
Practice Address - Fax:626-821-0141
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417930Medicaid
B50479Medicare UPIN
CAA41793Medicare ID - Type Unspecified
CA00A417930Medicaid