Healthcare Provider Details

I. General information

NPI: 1215952676
Provider Name (Legal Business Name): EMAD SAMIR FARAG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/01/2021
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 BROCKTON AVE STE 200
RIVERSIDE CA
92506-2658
US

IV. Provider business mailing address

7117 BROCKTON AVE STE 200
RIVERSIDE CA
92506-2658
US

V. Phone/Fax

Practice location:
  • Phone: 951-697-5460
  • Fax:
Mailing address:
  • Phone: 951-697-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA66905
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA66905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: