Basic Information
Provider Information | |||||||||
NPI: | 1871811430 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AWAN PROFESSIONAL MEDICAL CORP. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1525 WEBSTER ST | ||||||||
Address2: | SUITE A | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945334997 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074232510 | ||||||||
FaxNumber: | 7074254032 | ||||||||
Practice Location | |||||||||
Address1: | 1525 WEBSTER ST | ||||||||
Address2: | SUITE A | ||||||||
City: | FAIRFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 945334997 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074232506 | ||||||||
FaxNumber: | 7074291158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/06/2010 | ||||||||
LastUpdateDate: | 05/06/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AWAN | ||||||||
AuthorizedOfficialFirstName: | NAJAM | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7074232510 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | A26106 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.