Healthcare Provider Details

I. General information

NPI: 1982947628
Provider Name (Legal Business Name): MAGDY AZIZ KEROLLOS BEBAWY O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 E PALMDALE BLVD
PALMDALE CA
93550-4930
US

IV. Provider business mailing address

2503 COTTONWOOD TRL
CHINO HILLS CA
91709-1112
US

V. Phone/Fax

Practice location:
  • Phone: 661-267-0026
  • Fax:
Mailing address:
  • Phone: 909-235-1998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: