Provider Demographics
NPI:1578520144
Name:MED ONE FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:MED ONE FAMILY MEDICAL GROUP
Other - Org Name:AFDAL ALLAM MD
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AFDAL
Authorized Official - Middle Name:IBRAHIM
Authorized Official - Last Name:ALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-848-7757
Mailing Address - Street 1:8970 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-848-7757
Mailing Address - Fax:714-848-7760
Practice Address - Street 1:8970 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-848-7757
Practice Address - Fax:714-848-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094190Medicaid
A29287Medicare UPIN
I08195Medicare UPIN
C49074Medicare UPIN
WA80879AMedicare PIN
CAGR0094190Medicaid
WG83528AMedicare PIN