Healthcare Provider Details

I. General information

NPI: 1184860496
Provider Name (Legal Business Name): FARIED BANIMAHD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 E 4TH ST
SANTA ANA CA
92701-5115
US

IV. Provider business mailing address

1835 NEWPORT BLVD STE A109-559
COSTA MESA CA
92627-5031
US

V. Phone/Fax

Practice location:
  • Phone: 949-347-8721
  • Fax: 949-347-8709
Mailing address:
  • Phone: 949-347-8721
  • Fax: 949-347-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberA100516
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA100516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: