Provider Demographics
NPI:1942486790
Name:MALEK, MANOUCHEHR (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:
Last Name:MALEK
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 1:520 SUPERIOR AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3668
Mailing Address - Country:US
Mailing Address - Phone:949-720-9266
Mailing Address - Fax:
Practice Address - Street 1:520 SUPERIOR AVE STE 255
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3668
Practice Address - Country:US
Practice Address - Phone:949-720-9266
Practice Address - Fax:949-340-8034
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27205291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC27205Medicare PIN