Provider Demographics
NPI:1609859412
Name:OZOHAN, MARY LOU (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:OZOHAN
Suffix:
Gender:F
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:PO BOX 513969
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3969
Mailing Address - Country:US
Mailing Address - Phone:310-335-4065
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:5522 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3437
Practice Address - Country:US
Practice Address - Phone:818-997-1522
Practice Address - Fax:818-997-0705
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23566174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A235660Medicaid
CA00A235660Medicaid
CAWA23566OMedicare PIN
CAA85583Medicare UPIN
CAWA23566DMedicare PIN
CAWA23566JMedicare PIN
CAWA23566CMedicare PIN
CAWA23566FMedicare PIN
CAWA23566BMedicare PIN