MEDICARE: MRS. AMANI ELDESSOUKY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A56426	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528074044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANI ELDESSOUKY M.D.

Provider Business Mailing Address
First Line	:	1704 W MANCHESTER AVE
Second Line	:	SUITE 109
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-3034
Country	:	US
Telephone Number	:	323-778-8485
Fax Number	:	323-778-4452

Provider Business Practice Location Address
First Line	:	1704 W MANCHESTER AVE
Second Line	:	SUITE 109
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-3034
Country	:	US
Telephone Number	:	323-778-8485
Fax Number	:	310-778-4452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	12/12/2014

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