Healthcare Provider Details

I. General information

NPI: 1316969629
Provider Name (Legal Business Name): MICHAEL S MAEHARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 CLARK AVE
LONG BEACH CA
90815-2521
US

IV. Provider business mailing address

75 REMITTANCE DR DEPT 6008
CHICAGO IL
60675-6008
US

V. Phone/Fax

Practice location:
  • Phone: 562-597-4181
  • Fax: 562-597-7083
Mailing address:
  • Phone: 562-282-1419
  • Fax: 562-920-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA39815
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number39815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: