Basic Information
Provider Information | |||||||||
NPI: | 1447671185 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IMAGIWILL MED CO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1770 | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919441770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194641165 | ||||||||
FaxNumber: | 6195671011 | ||||||||
Practice Location | |||||||||
Address1: | 1350 COLUMBIA ST | ||||||||
Address2: | SUITE 800 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921013454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6193561446 | ||||||||
FaxNumber: | 6196184530 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/24/2013 | ||||||||
LastUpdateDate: | 12/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAWFIQUE | ||||||||
AuthorizedOfficialFirstName: | ARAZ | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6193561446 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A109527 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.