MEDICARE: DR. OSAZUWA OMEDE PSY.D.,PH.D.,MSAOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY13761	CA

General Provider Information

NPI Number	:	1134219181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OSAZUWA OMEDE PSY.D.,PH.D.,MSAOM

Provider Business Mailing Address
First Line	:	14921 BARNWALL ST
Second Line	:
City	:	LA MIRADA
State	:	CA
Zip	:	90638-4628
Country	:	US
Telephone Number	:	213-215-8019
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 S COMMONWEALTH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-4001
Country	:	US
Telephone Number	:	213-739-2359
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	11/01/2012

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