Healthcare Provider Details

I. General information

NPI: 1285900993
Provider Name (Legal Business Name): ALI YOUNES MEJADDAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 02/08/2023
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11370 ANDERSON ST STE 2100
LOMA LINDA CA
92354-3450
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8000
  • Fax:
Mailing address:
  • Phone: 909-558-2822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTR 2680
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA161930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: