Provider Demographics
NPI:1316978299
Name:MIKHAIL, MAGED S (MD)
Entity type:Individual
Prefix:
First Name:MAGED
Middle Name:S
Last Name:MIKHAIL
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:PO BOX 573446
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-3446
Mailing Address - Country:US
Mailing Address - Phone:818-654-0520
Mailing Address - Fax:818-654-0520
Practice Address - Street 1:18344 CLARK STREET
Practice Address - Street 2:SUITE #202
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2812
Practice Address - Country:US
Practice Address - Phone:818-654-0520
Practice Address - Fax:818-654-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45367207L00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G453670Medicaid
CAG45367AMedicare PIN
CAW20940Medicare PIN
CAWG45367CMedicare PIN