Healthcare Provider Details

I. General information

NPI: 1255372181
Provider Name (Legal Business Name): ABDUL SHUKOOR ENAYAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12550 HESPERIA RD STE 100
VICTORVILLE CA
92395-5873
US

IV. Provider business mailing address

200 W CENTER STREET PROMENADE STE 400
ANAHEIM CA
92805-3960
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6666
  • Fax: 760-947-5619
Mailing address:
  • Phone: 714-449-4800
  • Fax: 714-449-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMC16944
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC150664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: