Provider Demographics
NPI:1992052716
Name:GEBRAEL, MIKE HESHMAT
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:HESHMAT
Last Name:GEBRAEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13251 STANFORD DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7247
Mailing Address - Country:US
Mailing Address - Phone:714-457-9366
Mailing Address - Fax:
Practice Address - Street 1:22617 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-4342
Practice Address - Country:US
Practice Address - Phone:714-457-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCP0028493P172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver