Healthcare Provider Details

I. General information

NPI: 1396888152
Provider Name (Legal Business Name): ANTELOPE VALLEY UROLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44105 15TH ST W SUITE 302
LANCASTER CA
93534-4088
US

IV. Provider business mailing address

44105 15TH ST W SUITE 302
LANCASTER CA
93534-4088
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-3006
  • Fax: 661-949-8770
Mailing address:
  • Phone: 661-949-3006
  • Fax: 661-949-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC39635
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA39485
License Number StateCA

VIII. Authorized Official

Name: TAWFIK TIM HADAYA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 661-949-3006