Provider Demographics
NPI:1447381736
Name:FOUR M MEDICAL MART A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FOUR M MEDICAL MART A MEDICAL CORPORATION
Other - Org Name:SAN MIGUEL OCCUPATIONAL & URGENT CARE MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAHFOUZ
Authorized Official - Middle Name:M
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-994-0804
Mailing Address - Street 1:PO BOX 291040
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-9040
Mailing Address - Country:US
Mailing Address - Phone:818-994-0804
Mailing Address - Fax:818-994-4117
Practice Address - Street 1:11432 VANOWEN STREET
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-6220
Practice Address - Country:US
Practice Address - Phone:818-503-9999
Practice Address - Fax:818-503-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty