Provider Demographics
NPI:1992781322
Name:OHAERI, ANYIAM S
Entity type:Individual
Prefix:
First Name:ANYIAM
Middle Name:S
Last Name:OHAERI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-7185
Mailing Address - Country:US
Mailing Address - Phone:310-679-1319
Mailing Address - Fax:310-679-1719
Practice Address - Street 1:14023 CRENSHAW BLVD STE 3
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-9255
Practice Address - Country:US
Practice Address - Phone:310-679-1319
Practice Address - Fax:310-679-1719
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102608171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3972810001Medicare NSC