Provider Demographics
NPI:1629291554
Name:MAHMOUD A. KREIDIE
Entity Type:Organization
Organization Name:MAHMOUD A. KREIDIE
Other - Org Name:NEUROLOGY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KREIDIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-348-8880
Mailing Address - Street 1:26932 OSO PKWY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5815
Mailing Address - Country:US
Mailing Address - Phone:949-348-8880
Mailing Address - Fax:
Practice Address - Street 1:26932 OSO PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5815
Practice Address - Country:US
Practice Address - Phone:949-348-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA295282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A295280Medicaid
CAZZZ62117ZOtherBLUE SHIELD OF CALIFORNIA
CA=========OtherTIN
CAZZZ62117ZOtherBLUE SHIELD OF CALIFORNIA