Provider Demographics
NPI:1700890167
Name:HERMAN SARDJONO MD MEDICAL CORP
Entity Type:Organization
Organization Name:HERMAN SARDJONO MD MEDICAL CORP
Other - Org Name:HERMAN SARDJONO MD MEDICAL CORPORAT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SARDJONO MD
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:626-821-5305
Mailing Address - Street 1:72 W LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417930Medicaid
CA00A417930Medicaid