Healthcare Provider Details

I. General information

NPI: 1215622568
Provider Name (Legal Business Name): ALIA GHONEUM MD/PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 GATEWAY BLVD
FAIRFIELD CA
94533-6901
US

IV. Provider business mailing address

1550 GATEWAY BLVD
FAIRFIELD CA
94533-6900
US

V. Phone/Fax

Practice location:
  • Phone: 707-427-4310
  • Fax:
Mailing address:
  • Phone: 707-427-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: