Provider Demographics
NPI:1770670713
Name:ALBOUIDANI, MOHAMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:
Last Name:ALBOUIDANI
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:PO BOX 28387
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92809
Mailing Address - Country:US
Mailing Address - Phone:573-225-5767
Mailing Address - Fax:
Practice Address - Street 1:600 CITY PKWY W
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-539-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006027970207R00000X
CAA110080207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115618OtherILLINOIS LICENSE
MO2006027970OtherMISSOURI LICENSE