Provider Demographics
NPI:1346400819
Name:MAHMOUD AJANG M.D., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MAHMOUD AJANG M.D., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:AJANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-547-2882
Mailing Address - Street 1:3466 HIGHTIDE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6131
Mailing Address - Country:US
Mailing Address - Phone:310-547-2882
Mailing Address - Fax:310-547-3015
Practice Address - Street 1:378 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3338
Practice Address - Country:US
Practice Address - Phone:310-547-1801
Practice Address - Fax:310-547-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA377172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A377170Medicaid
CAA37717Medicare PIN
CAA28442Medicare UPIN