Provider Demographics
NPI:1255372181
Name:ENAYAT, ABDUL SHUKOOR (MD)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:SHUKOOR
Last Name:ENAYAT
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 1:200 W CENTER STREET PROMENADE STE 400
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:12550 HESPERIA RD STE 100
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5873
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-947-5619
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMC16944207R00000X
CAC150664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00614804OtherRAILROAD MEDICARE PTAN
TN44D0984814OtherCLIA
TN30987951Medicare PIN