Healthcare Provider Details

I. General information

NPI: 1114489598
Provider Name (Legal Business Name): NADINE M HAMMOUD DO, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12815 HEACOCK ST
MORENO VALLEY CA
92553-2836
US

IV. Provider business mailing address

12815 HEACOCK ST
MORENO VALLEY CA
92553-3116
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number20A19668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: