Provider Demographics
NPI:1972597250
Name:MAYEDA, MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MAYEDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6102 WARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-3137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17430 CRENSHAW BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-3400
Practice Address - Country:US
Practice Address - Phone:310-532-8900
Practice Address - Fax:310-532-4079
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8541T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8541Medicaid
CA8541Medicaid
CAGW894ZMedicare UPIN