Basic Information
| Provider Information | |||||||||
| NPI: | 1407861818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOJAVE RADIATION ONCOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 ELM AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Practice Location | |||||||||
| Address1: | 18280 SISKIYOU RD | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602421372 | ||||||||
| FaxNumber: | 7602421127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | ZIAULLA | ||||||||
| AuthorizedOfficialFirstName: | SYED | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5624926695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0050110 | 05 | CA | MEDICAID | 9673134 | 05 | CA | MEDICAID |