Provider Demographics
NPI:1891830907
Name:FEDERMAN, MYKE (MD)
Entity Type:Individual
Prefix:
First Name:MYKE
Middle Name:
Last Name:FEDERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYKE
Other - Middle Name:
Other - Last Name:DRAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:12-441 MDCC
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-6752
Mailing Address - Fax:310-794-6623
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:12-441 MDCC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-6752
Practice Address - Fax:310-794-6623
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA823262080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A823260Medicaid
CAGH183ZMedicare PIN