Provider Demographics
NPI:1649274176
Name:MAXIMOUS, TALAAT F (MD)
Entity type:Individual
Prefix:
First Name:TALAAT
Middle Name:F
Last Name:MAXIMOUS
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 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2654
Mailing Address - Country:US
Mailing Address - Phone:760-256-1004
Mailing Address - Fax:760-256-1055
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2654
Practice Address - Country:US
Practice Address - Phone:760-256-1004
Practice Address - Fax:760-255-9001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037825207X00000X
CAA38348207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93702Medicare UPIN
VAP00202403OtherRR/MEDICARE
VA022405A04Medicare PIN
B93702Medicare UPIN