Provider Demographics
NPI:1326034273
Name:DUSOL, MAURICE JR (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:DUSOL
Suffix:JR
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 1:1081 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-446-0121
Mailing Address - Fax:760-446-0734
Practice Address - Street 1:1041 N CHINA LAKE BLVD
Practice Address - Street 2:B
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3183
Practice Address - Country:US
Practice Address - Phone:760-446-6404
Practice Address - Fax:760-446-6415
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20524207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G205240Medicaid
A109OtherCHAMPUS
CABZ243ZMedicare PIN
CAA90652Medicare UPIN
CA00G205240Medicaid