Healthcare Provider Details

I. General information

NPI: 1821471442
Provider Name (Legal Business Name): ALI SYED HABIB D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

IV. Provider business mailing address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-1797
  • Fax:
Mailing address:
  • Phone: 657-241-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A16412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: