1104045061 NPI number — MAHFOUZ M. MICHAEL,M.D.,INC.

Table of content: (NPI 1104045061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104045061 NPI number — MAHFOUZ M. MICHAEL,M.D.,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAHFOUZ M. MICHAEL,M.D.,INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICA MEDICA SAN MIGUEL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104045061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 291040
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90029-9040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-994-0804
Provider Business Mailing Address Fax Number:
818-994-1288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7119 RITA AVE
Provider Second Line Business Practice Location Address:
SUITE C, E, F
Provider Business Practice Location Address City Name:
HUNTINGTON PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90255-4781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-582-4980
Provider Business Practice Location Address Fax Number:
323-582-4914
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MICHAEL
Authorized Official First Name:
MAHFOUZ
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
818-266-6432

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR001685B , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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