Provider Demographics
NPI:1245330364
Name:MED-PED I D INCORPORATED
Entity type:Organization
Organization Name:MED-PED I D INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:CHAWKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARFOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-679-5811
Mailing Address - Street 1:28078 BAXTER RD STE 320
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1404
Mailing Address - Country:US
Mailing Address - Phone:951-679-5811
Mailing Address - Fax:951-679-5844
Practice Address - Street 1:28078 BAXTER RD
Practice Address - Street 2:SUITE 320
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1402
Practice Address - Country:US
Practice Address - Phone:951-679-5811
Practice Address - Fax:951-679-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP1100X
CAA60874207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG72898Medicare UPIN
CAZZZ32562ZMedicare ID - Type Unspecified