MEDICARE: AGUSTINUS SUHARDJA MD

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	2085R0202X	Diagnostic Radiology Physician	04-34805	KS
2	2085R0202X	Diagnostic Radiology Physician	D0078407	MD
3	2085R0202X	Diagnostic Radiology Physician	0101256807	VA
4	2085R0202X	Diagnostic Radiology Physician	A89588	CA

General Provider Information

NPI Number	:	1235349473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTINUS SUHARDJA MD

Provider Business Mailing Address
First Line	:	PO BOX 6869
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92863-6869
Country	:	US
Telephone Number	:	714-571-5000
Fax Number	:	714-571-5055

Provider Business Practice Location Address
First Line	:	828 S GRAND AVE STE 104
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91740-4856
Country	:	US
Telephone Number	:	626-963-2057
Fax Number	:	626-963-4298

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	11/29/2021

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