Provider Demographics
NPI:1851746630
Name:ALFARAJ, WALLA (MD)
Entity Type:Individual
Prefix:
First Name:WALLA
Middle Name:
Last Name:ALFARAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 N ALTA VISTA BLVD APT 309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-8219
Mailing Address - Country:US
Mailing Address - Phone:713-314-6000
Mailing Address - Fax:
Practice Address - Street 1:1401 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3103
Practice Address - Country:US
Practice Address - Phone:760-326-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA162172207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1851746630Medicaid