Provider Demographics
NPI:1881679587
Name:TAKETA, RANDY (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:TAKETA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4901
Mailing Address - Country:US
Mailing Address - Phone:310-829-0055
Mailing Address - Fax:310-453-2971
Practice Address - Street 1:2901 WILSHIRE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4901
Practice Address - Country:US
Practice Address - Phone:310-829-0055
Practice Address - Fax:310-453-2971
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9103TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0283540001Medicare NSC
CAT95719Medicare UPIN
CAWOP9103AMedicare PIN