=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245055151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUTAHIR FARHAN MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 284 DUPONT ST STE 130
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-6029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-497-3749
-----------------------------------------------------
Fax | 954-405-8701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20810 BAKAL DR
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-2983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-497-3749
-----------------------------------------------------
Fax | 954-405-8701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MR. JOHN DARIUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 424-728-7877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------