Provider Demographics
NPI:1114928504
Name:MOSEBERRY, MELISSA DIANE (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:MOSEBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11539 HAWTHORNE BLVD
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2325
Mailing Address - Country:US
Mailing Address - Phone:310-675-5370
Mailing Address - Fax:310-531-2084
Practice Address - Street 1:505 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4611
Practice Address - Country:US
Practice Address - Phone:323-754-4090
Practice Address - Fax:310-531-2508
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A345690Medicaid
N14422BMedicare ID - Type Unspecified
CA00A345690Medicaid