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General NPI Number Information
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NPI Number | 1396063574
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Entity Type | Organization
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Legal Business Name | FARES ELGHAZI MD MEDICAL CORPORATION
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Dates
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Enumeration Date | 05/12/2010
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Last Update Date | 06/18/2010
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Provider Practice Location Address
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Address Line | 1818 N ORANGE GROVE AVE SUITE 300
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City | POMONA
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State | CA
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Zip | 91767-3028
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Country | US
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Telephone | 909-620-7876
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Fax | 909-463-2434
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Provider Business Mailing Address
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Address Line | 1818 N ORANGE GROVE AVE SUITE 300
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City | POMONA
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State | CA
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Zip | 91767-3028
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Country | US
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Telephone | 909-620-7876
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Fax | 909-463-2434
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Authorized Official
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Title or Position | OWNER
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Name | DR. FARES ELGHAZI
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Credential | M.D.
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Telephone | 909-620-7876
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | C042219
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License Number State | CA
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