Provider Demographics
NPI:1598783185
Name:SHWAYDER, MICHAEL WARREN TODD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN TODD
Last Name:SHWAYDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 PARK TERRACE
Mailing Address - Street 2:SUITE 530B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-301-0015
Mailing Address - Fax:310-301-4882
Practice Address - Street 1:6801 PARK TERRACE
Practice Address - Street 2:SUITE 530B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-301-0015
Practice Address - Fax:310-301-4882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G352050Medicaid
CAA46260Medicare UPIN
CAG35205Medicare ID - Type Unspecified