Basic Information
| Provider Information | |||||||||
| NPI: | 1649490822 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAHFOUZ M. MICHAEL,M.D.,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINICA MEDICA SAN MIGUEL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 291040 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900299040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189940804 | ||||||||
| FaxNumber: | 8189941288 | ||||||||
| Practice Location | |||||||||
| Address1: | 2618 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900182627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237309000 | ||||||||
| FaxNumber: | 3237304825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | MICHAEL | ||||||||
| AuthorizedOfficialFirstName: | MAHFOUZ | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8182666432 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0016852 | 05 | CA | MEDICAID |