Provider Demographics
NPI:1033877048
Name:MOMIN, FAHAD F (CMD)
Entity Type:Individual
Prefix:
First Name:FAHAD
Middle Name:F
Last Name:MOMIN
Suffix:
Gender:M
Credentials:CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 S SANTA FE AVE APT 726
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90021-1371
Mailing Address - Country:US
Mailing Address - Phone:281-650-8643
Mailing Address - Fax:
Practice Address - Street 1:1100 N STATE ST # A1B133
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5000
Practice Address - Country:US
Practice Address - Phone:323-409-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20013172085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology