MEDICARE: DR. RANDY TAKETA O.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	152W00000X	Optometrist	OPT9103TPA	CA

General Provider Information

NPI Number	:	1881679587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY TAKETA O.D.

Provider Business Mailing Address
First Line	:	2901 WILSHIRE BLVD
Second Line	:	SUITE 100
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4901
Country	:	US
Telephone Number	:	310-829-0055
Fax Number	:	310-453-2971

Provider Business Practice Location Address
First Line	:	2901 WILSHIRE BLVD
Second Line	:	SUITE 100
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4901
Country	:	US
Telephone Number	:	310-829-0055
Fax Number	:	310-453-2971

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	03/17/2011

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