Provider Demographics
NPI:1851459325
Name:MONJI, GARY TAKEO (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:TAKEO
Last Name:MONJI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 N SAN FERNANDO BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1208
Mailing Address - Country:US
Mailing Address - Phone:818-848-6659
Mailing Address - Fax:818-848-7911
Practice Address - Street 1:153 N SAN FERNANDO BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1208
Practice Address - Country:US
Practice Address - Phone:818-848-6659
Practice Address - Fax:818-848-7911
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADV547ZOtherMEDICARE PTAN
CASD0093120Medicaid
CA1054620001Medicare NSC
CASD0093120Medicaid
CA1054620001Medicare NSC