Provider Demographics
NPI:1053364125
Name:MAEDA, RENWICK YOSHIO (PT MPT OCS GCFP)
Entity type:Individual
Prefix:MR
First Name:RENWICK
Middle Name:YOSHIO
Last Name:MAEDA
Suffix:
Gender:M
Credentials:PT MPT OCS GCFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2901 WILSHIRE BLVD
Mailing Address - Street 2:440
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4901
Mailing Address - Country:US
Mailing Address - Phone:310-315-9711
Mailing Address - Fax:310-315-9349
Practice Address - Street 1:1600 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3626
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P44002Medicare UPIN
CAWPT154868Medicare ID - Type Unspecified