Provider Demographics
NPI:1669689220
Name:OYAMA, MARK MITSUYUKI (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MITSUYUKI
Last Name:OYAMA
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 1:1260 15TH ST
Mailing Address - Street 2:SUITE 802
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1135
Mailing Address - Country:US
Mailing Address - Phone:310-393-6388
Mailing Address - Fax:310-393-3097
Practice Address - Street 1:1260 15TH ST
Practice Address - Street 2:SUITE 802
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1135
Practice Address - Country:US
Practice Address - Phone:310-393-6388
Practice Address - Fax:310-393-3097
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist