Provider Demographics
NPI:1780636167
Name:HAFEZ, MOHAMED AMR (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:AMR
Last Name:HAFEZ
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 1:3102 E. HIGHLAND AVENUE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369
Mailing Address - Country:US
Mailing Address - Phone:909-425-7679
Mailing Address - Fax:909-425-6635
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7679
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48947207Q00000X, 2083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41935Medicare UPIN
00A489470Medicare ID - Type Unspecified