Provider Demographics
NPI:1265444723
Name:AL-HAFEZ, MOHAMAD ALTAYEB (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMAD ALTAYEB
Middle Name:
Last Name:AL-HAFEZ
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 1:560 HAIGHT ST.
Mailing Address - Street 2:UNIT 101
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117
Mailing Address - Country:US
Mailing Address - Phone:415-845-6040
Mailing Address - Fax:
Practice Address - Street 1:1221 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2829
Practice Address - Country:US
Practice Address - Phone:360-754-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD158168207QH0002X, 207R00000X
WAMD00040497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH18562Medicare UPIN