Provider Demographics
NPI:1114581881
Name:MICHAEL KOBAYASHI, OD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL KOBAYASHI, OD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KOBAYASHI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-766-4510
Mailing Address - Street 1:18204 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3819
Mailing Address - Country:US
Mailing Address - Phone:310-719-2020
Mailing Address - Fax:310-719-2068
Practice Address - Street 1:18204 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3819
Practice Address - Country:US
Practice Address - Phone:310-719-2020
Practice Address - Fax:310-719-2068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-27
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGA664ZOtherMEDICARE