Provider Demographics
NPI:1518723394
Name:ABDELBASET BIN MYRON, MALLEK IBRAHIM
Entity Type:Individual
Prefix:
First Name:MALLEK
Middle Name:IBRAHIM
Last Name:ABDELBASET BIN MYRON
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 1:9465 ROSEMARIE CT
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-2858
Mailing Address - Country:US
Mailing Address - Phone:951-355-3338
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4320
Practice Address - Country:US
Practice Address - Phone:424-354-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker