Provider Demographics
NPI:1134219181
Name:OMEDE, OSAZUWA (PSYD,PHD,MSAOM)
Entity type:Individual
Prefix:DR
First Name:OSAZUWA
Middle Name:
Last Name:OMEDE
Suffix:
Gender:M
Credentials:PSYD,PHD,MSAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14921 BARNWALL ST
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-4628
Mailing Address - Country:US
Mailing Address - Phone:213-215-8019
Mailing Address - Fax:
Practice Address - Street 1:600 S COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-4001
Practice Address - Country:US
Practice Address - Phone:213-739-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13761103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical