Provider Demographics
NPI:1467667535
Name:OBEDIAN, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:OBEDIAN
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 1:18036 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3516
Mailing Address - Country:US
Mailing Address - Phone:818-345-2668
Mailing Address - Fax:818-345-6480
Practice Address - Street 1:18036 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3516
Practice Address - Country:US
Practice Address - Phone:818-345-2668
Practice Address - Fax:818-345-6480
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101750332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02195FMedicaid
CADME02195FMedicaid