Healthcare Provider Details

I. General information

NPI: 1780636167
Provider Name (Legal Business Name): MOHAMED AMR HAFEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

IV. Provider business mailing address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7679
  • Fax: 909-425-6635
Mailing address:
  • Phone: 909-425-7679
  • Fax: 909-425-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48947
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA48947
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA48947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: