Provider Demographics
NPI:1700055274
Name:FERAS AND HISHAM A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FERAS AND HISHAM A MEDICAL CORPORATION
Other - Org Name:ST. JOHN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOSEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEFRAWY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-464-0520
Mailing Address - Street 1:2112 S GAREY AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5600
Mailing Address - Country:US
Mailing Address - Phone:909-464-0520
Mailing Address - Fax:909-464-0523
Practice Address - Street 1:2112 S GAREY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5600
Practice Address - Country:US
Practice Address - Phone:909-464-0520
Practice Address - Fax:909-464-0523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30899208D00000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083747612Medicaid
CA1568747236Medicaid