Healthcare Provider Details

I. General information

NPI: 1487716544
Provider Name (Legal Business Name): SAMUEL OSAMU MAYEDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W LA VETA AVE STE 420
ORANGE CA
92868-4226
US

IV. Provider business mailing address

1140 W LA VETA AVE STE 420
ORANGE CA
92868-4226
US

V. Phone/Fax

Practice location:
  • Phone: 714-285-1904
  • Fax: 714-571-5979
Mailing address:
  • Phone: 714-285-1904
  • Fax: 714-571-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC36879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: