Provider Demographics
NPI:1790958262
Name:HUSSAIN AL-DARSANI M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:HUSSAIN AL-DARSANI M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUSSAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-DARSANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-287-0440
Mailing Address - Street 1:13193 CENTRAL AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4179
Mailing Address - Country:US
Mailing Address - Phone:909-287-0440
Mailing Address - Fax:
Practice Address - Street 1:13193 CENTRAL AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4179
Practice Address - Country:US
Practice Address - Phone:909-287-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA687821207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A6878210Medicaid
CA00A687821Medicare PIN
CA00A6878210Medicaid