Provider Demographics
NPI:1821529611
Name:MEDEROS, MICHAEL ALEXANDER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:MEDEROS
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 1:10833 LE CONTE AVE
Mailing Address - Street 2:72-235 CHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1749
Mailing Address - Country:US
Mailing Address - Phone:310-794-4315
Mailing Address - Fax:310-267-0369
Practice Address - Street 1:757 WESTWOOD PLZ
Practice Address - Street 2:SURGERY
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-7419
Practice Address - Country:US
Practice Address - Phone:310-794-4315
Practice Address - Fax:310-267-0369
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program