Provider Demographics
NPI:1053486605
Name:ALLAM, AFDAL IBRAHIM (MD)
Entity Type:Individual
Prefix:
First Name:AFDAL
Middle Name:IBRAHIM
Last Name:ALLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8970 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3211
Mailing Address - Country:US
Mailing Address - Phone:714-848-7757
Mailing Address - Fax:
Practice Address - Street 1:8970 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3211
Practice Address - Country:US
Practice Address - Phone:714-848-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094190Medicaid
CAGR0094190Medicaid
CAW14714Medicare PIN