Provider Demographics
NPI:1114946340
Name:HADDAD-WILSON, MOUNA (MD)
Entity Type:Individual
Prefix:
First Name:MOUNA
Middle Name:
Last Name:HADDAD-WILSON
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:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-794-3682
Mailing Address - Fax:909-389-1318
Practice Address - Street 1:1600 E CITRUS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4270
Practice Address - Country:US
Practice Address - Phone:909-794-3682
Practice Address - Fax:909-389-1318
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75228207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G752280Medicaid
CA00G752280Medicaid
00G752280Medicare ID - Type Unspecified