Healthcare Provider Details

I. General information

NPI: 1205829975
Provider Name (Legal Business Name): MARYA MIYAMOTO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 N FIGUEROA ST
LOS ANGELES CA
90042-4232
US

IV. Provider business mailing address

6000 N FIGUEROA ST
LOS ANGELES CA
90042-4232
US

V. Phone/Fax

Practice location:
  • Phone: 323-254-5291
  • Fax: 323-254-9026
Mailing address:
  • Phone: 323-254-5291
  • Fax: 323-254-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA 79492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: