Healthcare Provider Details

I. General information

NPI: 1992972848
Provider Name (Legal Business Name): OTTONIEL ANTONIO MEJIA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UCLA MEDICAL PLZ # 460
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

100 UCLA MEDICAL PLZ # 460
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-443-8999
  • Fax: 310-208-4847
Mailing address:
  • Phone: 310-443-8999
  • Fax: 310-208-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4779
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: