Healthcare Provider Details

I. General information

NPI: 1518267616
Provider Name (Legal Business Name): WAIS NEZAMI ARSALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2010
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-5083
  • Fax: 909-427-5022
Mailing address:
  • Phone: 909-427-5083
  • Fax: 909-427-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA114365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: