Provider Demographics
NPI:1912182916
Name:FAZIL, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:FAZIL
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 1:17385 SUMMER OAK PL
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-9002
Mailing Address - Country:US
Mailing Address - Phone:562-789-1356
Mailing Address - Fax:562-222-2225
Practice Address - Street 1:5060 ROSEMEAD BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2402
Practice Address - Country:US
Practice Address - Phone:562-789-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35835208600000X
CAA35835A282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A358350OtherBLUE CROSS BLUE SHIELD
CAA27917Medicare UPIN
CA00A358350OtherBLUE CROSS BLUE SHIELD