Provider Demographics
NPI:1831868645
Name:HANDOKO, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:HANDOKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 REDBIRD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-2823
Mailing Address - Country:US
Mailing Address - Phone:408-623-8284
Mailing Address - Fax:
Practice Address - Street 1:1291 S BERNARDO AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2060
Practice Address - Country:US
Practice Address - Phone:408-245-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
459315OtherNBCOT