Healthcare Provider Details

I. General information

NPI: 1598847725
Provider Name (Legal Business Name): MICHAEL J OBRIEN JR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 W 6TH ST
SAN PEDRO CA
90731-2521
US

IV. Provider business mailing address

575 W 6TH ST
SAN PEDRO CA
90731-2521
US

V. Phone/Fax

Practice location:
  • Phone: 310-832-1348
  • Fax: 310-832-2722
Mailing address:
  • Phone: 310-832-1348
  • Fax: 310-832-2722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP6305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: