Healthcare Provider Details

I. General information

NPI: 1578957429
Provider Name (Legal Business Name): NOUR ALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR # MC0834
LA JOLLA CA
92093-5004
US

IV. Provider business mailing address

9500 GILMAN DR # MC0834
LA JOLLA CA
92093-5004
US

V. Phone/Fax

Practice location:
  • Phone: 515-771-2899
  • Fax:
Mailing address:
  • Phone: 515-771-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA167133
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number01084858A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: