MEDICARE: DR. JOHN GLENN TAKETA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	G29937	CA

General Provider Information

NPI Number	:	1124013057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN GLENN TAKETA M.D.

Provider Business Mailing Address
First Line	:	5011 SHORELINE WAY
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93035-2842
Country	:	US
Telephone Number	:	805-760-4662
Fax Number	:

Provider Business Practice Location Address
First Line	:	5011 SHORELINE WAY
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93035
Country	:	US
Telephone Number	:	805-760-4662
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	09/24/2018

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