Provider Demographics
NPI:1912919820
Name:REDER, MICHAEL STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:REDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 VENTURA BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2011
Mailing Address - Country:US
Mailing Address - Phone:818-986-1200
Mailing Address - Fax:818-986-3011
Practice Address - Street 1:16500 VENTURA BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2011
Practice Address - Country:US
Practice Address - Phone:818-986-1200
Practice Address - Fax:818-986-3011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34552207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1089517Medicaid
CA1089517Medicaid
CAA35653Medicare UPIN