Basic Information
| Provider Information | |||||||||
| NPI: | 1447337241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGED M FARAGALLA, MD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2542 E FLORENCE AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WALNUT PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902554774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235848700 | ||||||||
| FaxNumber: | 3235845472 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 N MEDNIK AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900221326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233266700 | ||||||||
| FaxNumber: | 3232620006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | BEBAWY | ||||||||
| AuthorizedOfficialFirstName: | NAGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3235848700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1447337241 | 05 | CA | MEDICAID |