Provider Demographics
NPI:1407838105
Name:YUSUFALY, IMDAD III (MD)
Entity Type:Individual
Prefix:
First Name:IMDAD
Middle Name:
Last Name:YUSUFALY
Suffix:III
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 1:36243 INLAND VALLEY DR
Mailing Address - Street 2:STE 170
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9548
Mailing Address - Country:US
Mailing Address - Phone:951-677-1767
Mailing Address - Fax:951-677-5084
Practice Address - Street 1:36243 INLAND VALLEY DR
Practice Address - Street 2:STE 170
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9548
Practice Address - Country:US
Practice Address - Phone:951-677-1767
Practice Address - Fax:951-677-5084
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA509312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA509310Medicaid
OOA509310Medicare ID - Type Unspecified
E24756Medicare UPIN