Provider Demographics
NPI:1871841692
Name:MMJ MEDICAL INC,
Entity Type:Organization
Organization Name:MMJ MEDICAL INC,
Other - Org Name:GASTROENTEROLOGY AND THERAPEUTIC ENDOSCOPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD/MPH
Authorized Official - Phone:949-813-5115
Mailing Address - Street 1:29 PRAIRIE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-8840
Mailing Address - Country:US
Mailing Address - Phone:949-825-5188
Mailing Address - Fax:949-825-5189
Practice Address - Street 1:1810 FULLERTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881
Practice Address - Country:US
Practice Address - Phone:951-934-0505
Practice Address - Fax:951-934-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46078207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty