=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154774933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMAN GUIRGIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 07/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 COXWELL AVENUE
-----------------------------------------------------
City | TORONTO
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | M4C 3E7
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 416-469-6580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3812 MONTEGO DR
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-903-2601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C55832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------