Provider Demographics
NPI:1164859385
Name:PEDIATRIC ADOLESCENT CLINIC
Entity Type:Organization
Organization Name:PEDIATRIC ADOLESCENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAOUF
Authorized Official - Middle Name:AZIZ
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:909-946-4175
Mailing Address - Street 1:1214 ADRIANA WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784
Mailing Address - Country:US
Mailing Address - Phone:909-946-4155
Mailing Address - Fax:909-949-8836
Practice Address - Street 1:1214 ADRIANA WAY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1742
Practice Address - Country:US
Practice Address - Phone:909-946-4155
Practice Address - Fax:909-949-8836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE333272080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty