Provider Demographics
NPI:1376697599
Name:OMIDI, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:OMIDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9001 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1838
Mailing Address - Country:US
Mailing Address - Phone:310-273-8885
Mailing Address - Fax:
Practice Address - Street 1:9001 WILSHIRE BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1838
Practice Address - Country:US
Practice Address - Phone:310-273-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA845192086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH89807Medicare UPIN