Provider Demographics
NPI:1679197776
Name:MUHTASEB, FARIS TALAL
Entity Type:Individual
Prefix:
First Name:FARIS
Middle Name:TALAL
Last Name:MUHTASEB
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 1:1010 WEST ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-4245
Mailing Address - Country:US
Mailing Address - Phone:760-583-6624
Mailing Address - Fax:
Practice Address - Street 1:1010 WEST ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-4245
Practice Address - Country:US
Practice Address - Phone:760-583-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95827600G19206Medicaid