1720378508 NPI number — MAGED M FARAGALLA, MD, INC

Table of content: (NPI 1720378508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720378508 NPI number — MAGED M FARAGALLA, MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGED M FARAGALLA, MD, 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:
Provider Other Organization Name Type Code:
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:
1720378508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3624 MARTIN LUTHER KING JR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90262-2607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-603-9300
Provider Business Mailing Address Fax Number:
310-603-1200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3624 MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90262-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-603-9300
Provider Business Practice Location Address Fax Number:
310-603-1200
Provider Enumeration Date:
04/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MEHRTASH
Authorized Official First Name:
ATA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT / OWNER
Authorized Official Telephone Number:
562-531-3331

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720378508 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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