=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134219181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OSAZUWA OMEDE PSY.D.,PH.D.,MSAOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 11/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S COMMONWEALTH AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90005-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-739-2359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14921 BARNWALL ST
-----------------------------------------------------
City | LA MIRADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90638-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-215-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY13761
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------