Provider Demographics
NPI:1154353829
Name:AL-SADEK, MOHAMED FEKRY (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:FEKRY
Last Name:AL-SADEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 OCEAN VIEW AVE
Mailing Address - Street 2:APT. #C
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2666
Mailing Address - Country:US
Mailing Address - Phone:805-773-6811
Mailing Address - Fax:
Practice Address - Street 1:117 W BUNNY AVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-2805
Practice Address - Country:US
Practice Address - Phone:805-739-3890
Practice Address - Fax:805-347-7697
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89182207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891820Medicaid
CA00A891820Medicaid
CAWA89182AMedicare PIN
CAI49103Medicare UPIN