Provider Demographics
NPI:1396259149
Name:SOUTHERN CALIFORNIA DOCTORS PROF MEDICAL CORP
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA DOCTORS PROF MEDICAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-847-6900
Mailing Address - Street 1:PO BOX 2111
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92814-0111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 S BROOKHURST ST STE A
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-4321
Practice Address - Country:US
Practice Address - Phone:714-494-1331
Practice Address - Fax:714-494-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102841261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396958237Medicaid