Provider Demographics
NPI:1598847725
Name:OBRIEN JR, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:OBRIEN JR
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 1:575 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2521
Mailing Address - Country:US
Mailing Address - Phone:310-832-1348
Mailing Address - Fax:310-832-2722
Practice Address - Street 1:575 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2521
Practice Address - Country:US
Practice Address - Phone:310-832-1348
Practice Address - Fax:310-832-2722
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP6305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0929300001Medicare NSC
CAT70104Medicare UPIN