Basic Information
Provider Information
NPI: 1003140948
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAWAD
FirstName: JOE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1800 WESTERN AVE STE 204
Address2:  
City: SAN BERNARDINO
State: CA
PostalCode: 924111353
CountryCode: US
TelephoneNumber: 9094749952
FaxNumber: 9094749951
Practice Location
Address1: 1800 WESTERN AVE STE 204
Address2:  
City: SAN BERNARDINO
State: CA
PostalCode: 92411
CountryCode: US
TelephoneNumber: 9094749952
FaxNumber: 9094749951
Other Information
ProviderEnumerationDate: 09/24/2009
LastUpdateDate: 09/10/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207V00000XA109432CAY Allopathic & Osteopathic PhysiciansObstetrics & Gynecology 

ID Information
IDTypeStateIssuerDescription
00A109432005CA MEDICAID


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