Individual
AGUSTINUS SUHARDJA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
828 S GRAND AVE STE 104, GLENDORA, CA 91740-4856
(626) 963-2057
(626) 963-4298
Mailing address
PO BOX 6869, ORANGE, CA 92863-6869
(714) 571-5000
(714) 571-5055
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
0101256807
VA
2085R0202X
Diagnostic Radiology Physician
04-34805
KS
2085R0202X
Diagnostic Radiology Physician
Primary
A89588
CA
2085R0202X
Diagnostic Radiology Physician
D0078407
MD
Other
Enumeration date
05/23/2007
Last updated
11/29/2021
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