Provider Demographics
NPI:1881629350
Name:NOUR, FRED ZACHARY (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:ZACHARY
Last Name:NOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FARID
Other - Middle Name:ZAKY KHELLAH
Other - Last Name:NOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26691 PLAZA
Mailing Address - Street 2:STE 235
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6329
Mailing Address - Country:US
Mailing Address - Phone:949-364-9054
Mailing Address - Fax:949-364-6171
Practice Address - Street 1:26691 PLAZA
Practice Address - Street 2:STE 235
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6329
Practice Address - Country:US
Practice Address - Phone:949-364-9054
Practice Address - Fax:949-364-6171
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC544012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065960Medicaid
IN000000502077OtherANTHEM
IL2201682OtherBLUE CROSS BLUE SHIELD
IN200846240Medicaid
IL2201682OtherBLUE CROSS BLUE SHIELD
IL755851Medicare ID - Type UnspecifiedMEDICARE
IL036065960Medicaid
CAFN325ZMedicare PIN
CAFN322AMedicare PIN
IN716700DDMedicare PIN