Basic Information
| Provider Information | |||||||||
| NPI: | 1609953603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOROUR | ||||||||
| FirstName: | NAGUI | ||||||||
| MiddleName: | NABIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 S FAIRMONT AVE #100 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093342010 | ||||||||
| FaxNumber: | 2093340132 | ||||||||
| Practice Location | |||||||||
| Address1: | 999 S FAIRMONT AVE #100 | ||||||||
| Address2: | LODI | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093342010 | ||||||||
| FaxNumber: | 2093340132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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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 | 2086S0129X | A312100 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0200005210 | 01 | CA | RAILROAD MEDICARE | OTHER | 942658928 | 01 | CA | COMMERICAL INSURANCE | OTHER | 00A312100 | 05 | CA | MEDICAID |