Basic Information
| Provider Information | |||||||||
| NPI: | 1255372181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENAYAT | ||||||||
| FirstName: | ABDUL | ||||||||
| MiddleName: | SHUKOOR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W CENTER STREET PROMENADE STE 400 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928053960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494800 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 12550 HESPERIA RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7609475619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MC16944 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | C150664 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00614804 | 01 | TN | RAILROAD MEDICARE PTAN | OTHER | 44D0984814 | 01 | TN | CLIA | OTHER |