Provider Demographics
NPI:1740245323
Name:BAGH, MOHAMAD IZZAT (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:IZZAT
Last Name:BAGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4030
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-4030
Mailing Address - Country:US
Mailing Address - Phone:714-992-4444
Mailing Address - Fax:714-879-9999
Practice Address - Street 1:10900 WARNER AVE
Practice Address - Street 2:SUITE 101A
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3846
Practice Address - Country:US
Practice Address - Phone:714-698-1270
Practice Address - Fax:714-962-7261
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55324207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A553240Medicaid
CAG80923Medicare UPIN
CAAQ264ZMedicare PIN
CA00A553240Medicaid