Provider Demographics
NPI:1376895615
Name:GHATTAS, MEDHAT LABIB
Entity Type:Individual
Prefix:
First Name:MEDHAT
Middle Name:LABIB
Last Name:GHATTAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 MITCHELL AVE
Mailing Address - Street 2:#56
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6324
Mailing Address - Country:US
Mailing Address - Phone:714-757-3801
Mailing Address - Fax:
Practice Address - Street 1:1777 MITCHELL AVE
Practice Address - Street 2:#56
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6324
Practice Address - Country:US
Practice Address - Phone:714-757-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist