Provider Demographics
NPI:1306159249
Name:FAHEEM M JUKAKU MD INC
Entity type:Organization
Organization Name:FAHEEM M JUKAKU MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FAHEEM
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUKAKU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-232-4856
Mailing Address - Street 1:12318 WINDCHIME PL
Mailing Address - Street 2:APT C
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3160
Mailing Address - Country:US
Mailing Address - Phone:951-232-4856
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:ROOM NO. B2049
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-232-4856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty