Provider Demographics
NPI:1366500266
Name:MOUSTAFA, MOUSTAFA HUSSEIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUSTAFA
Middle Name:HUSSEIN
Last Name:MOUSTAFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1515 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7092
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2344
Practice Address - Fax:818-502-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53517207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA53517BMedicare PIN
CAG83821Medicare UPIN