Pediatric Adolescent Clinic

Primary specialty

Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X

License

AFE33327 Issued in CA

Legal business name

PEDIATRIC ADOLESCENT CLINIC

Practice address

1214 Adriana Way
Upland, CA 91784-1742

Phone

(909) 946-4155

Fax

(909) 949-8836

NPI assigned

Oct 2, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Raouf Aziz Ibrahim I, M.D.

Title

Pediatrician

Phone

(909) 946-4175

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1380672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380672000000",
    "number": "1164859385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1214 ADRIANA WAY",
            "city": "UPLAND",
            "state": "CA",
            "postal_code": "91784",
            "telephone_number": "909-946-4155",
            "fax_number": "909-949-8836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1214 ADRIANA WAY",
            "city": "UPLAND",
            "state": "CA",
            "postal_code": "917841742",
            "telephone_number": "909-946-4155",
            "fax_number": "909-949-8836"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ADOLESCENT CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-02",
        "last_updated": "2013-10-02",
        "status": "A",
        "authorized_official_last_name": "IBRAHIM",
        "authorized_official_first_name": "RAOUF",
        "authorized_official_middle_name": "AZIZ",
        "authorized_official_title_or_position": "PEDIATRICIAN",
        "authorized_official_telephone_number": "909-946-4175",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "I",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "CA",
            "license": "AFE33327",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Pediatric Adolescent Medicine Physician in Upland, CA
• Providers in Upland, CA by specialty
• Pediatric Adolescent Medicine Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.