Healthcare Provider Details

I. General information

NPI: 1245330364
Provider Name (Legal Business Name): MED-PED I D INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD SUITE 320
MURRIETA CA
92563-1402
US

IV. Provider business mailing address

28078 BAXTER RD STE 320
MURRIETA CA
92563-1404
US

V. Phone/Fax

Practice location:
  • Phone: 951-679-5811
  • Fax: 951-679-5844
Mailing address:
  • Phone: 951-679-5811
  • Fax: 951-679-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA60874
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHAWKI HARFOUCH
Title or Position: EMPLOYEE
Credential: MD
Phone: 951-679-5811