Provider Demographics
NPI:1073541157
Name:MOUSHABEK, ROGER ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALBERT
Last Name:MOUSHABEK
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 1:12370 HESPERIA RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-952-1222
Mailing Address - Fax:760-952-1074
Practice Address - Street 1:12370 HESPERIA RD
Practice Address - Street 2:SUITE 6
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7719
Practice Address - Country:US
Practice Address - Phone:760-952-1222
Practice Address - Fax:760-952-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE-25281Medicare UPIN
CAE-25281Medicare UPIN