Healthcare Provider Details

I. General information

NPI: 1124374889
Provider Name (Legal Business Name): HIGH DESERT SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17077 MAIN ST
HESPERIA CA
92345-6071
US

IV. Provider business mailing address

17095 MAIN ST
HESPERIA CA
92345-6004
US

V. Phone/Fax

Practice location:
  • Phone: 760-956-4128
  • Fax: 760-949-8572
Mailing address:
  • Phone: 760-241-6666
  • Fax: 760-241-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ZIAD R. EL-HAJJAOUI
Title or Position: MEDICAL DIRRECTOR
Credential: MD
Phone: 766-241-6666