Provider Demographics
NPI:1396888152
Name:ANTELOPE VALLEY UROLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:ANTELOPE VALLEY UROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAWFIK
Authorized Official - Middle Name:TIM
Authorized Official - Last Name:HADAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-949-3006
Mailing Address - Street 1:44105 15TH ST W
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4088
Mailing Address - Country:US
Mailing Address - Phone:661-949-3006
Mailing Address - Fax:661-949-8770
Practice Address - Street 1:44105 15TH ST W
Practice Address - Street 2:SUITE 302
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4088
Practice Address - Country:US
Practice Address - Phone:661-949-3006
Practice Address - Fax:661-949-8770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39635174400000X
CAA39485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076830Medicaid
CAZZZ53170ZOtherBLUE SHIELD
CAA85293Medicare UPIN
CAA37184Medicare UPIN
CAWA39485EMedicare ID - Type Unspecified
CAGR0076830Medicaid