Provider Demographics
NPI:1134475171
Name:W. AL-FADLY, M.D., INC
Entity Type:Organization
Organization Name:W. AL-FADLY, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALEED
Authorized Official - Middle Name:S
Authorized Official - Last Name:AL-FADLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-324-1183
Mailing Address - Street 1:16000 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4552
Mailing Address - Country:US
Mailing Address - Phone:310-324-1183
Mailing Address - Fax:310-324-4358
Practice Address - Street 1:16000 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4552
Practice Address - Country:US
Practice Address - Phone:310-324-1183
Practice Address - Fax:310-324-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20545261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A205453Medicaid
CA1215936224Medicare PIN
CA00A205453Medicaid