Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | A42526 | CA |
NPI | 1164512281 |
---|---|
Provider Name | Dr. Mohammad S Kanakriyeh |
First Address | San Bernardino, CA 92408 |
Second Address | San Bernardino, CA 92408 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 12/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A425260 | (05) | CA |
330698865 | BLUE CROSS (01) | CA |
A29597 | (02) | |
ZZZ51351Z | BLUE SHIELD (01) | CA |