Provider Demographics
NPI:1568480929
Name:TAKEI, GLENN K (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:K
Last Name:TAKEI
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 1:931 BUENA VISTA ST
Mailing Address - Street 2:STE 505
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1727
Mailing Address - Country:US
Mailing Address - Phone:626-357-9931
Mailing Address - Fax:626-359-0739
Practice Address - Street 1:931 BUENA VISTA ST
Practice Address - Street 2:STE 505
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1712
Practice Address - Country:US
Practice Address - Phone:626-357-9931
Practice Address - Fax:626-359-0739
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35093207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G350930Medicaid
CA00G350930Medicaid
CAG35093Medicare PIN