Provider Demographics
NPI:1760595029
Name:ALWAN, MOUHANAD MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUHANAD
Middle Name:MARK
Last Name:ALWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SAN BERNARDINO RD STE 205
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4985
Mailing Address - Country:US
Mailing Address - Phone:909-981-9991
Mailing Address - Fax:909-981-1325
Practice Address - Street 1:1310 SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4979
Practice Address - Country:US
Practice Address - Phone:909-981-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44569207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44569OtherSTATE LICENSE
CAA78587Medicare ID - Type Unspecified