Provider Demographics
NPI:1790799682
Name:MOEDJONO, SRI (MD)
Entity Type:Individual
Prefix:DR
First Name:SRI
Middle Name:
Last Name:MOEDJONO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21231 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5501
Mailing Address - Country:US
Mailing Address - Phone:310-792-4567
Mailing Address - Fax:310-316-2677
Practice Address - Street 1:21231 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5501
Practice Address - Country:US
Practice Address - Phone:310-792-4567
Practice Address - Fax:310-316-2677
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31755170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics