Provider Demographics
NPI:1609952431
Name:HABIB MOUSSA BASHOURA MD INC
Entity Type:Organization
Organization Name:HABIB MOUSSA BASHOURA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:HABIB
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHOURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-596-4879
Mailing Address - Street 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750
Mailing Address - Country:US
Mailing Address - Phone:909-596-4879
Mailing Address - Fax:909-596-6612
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750
Practice Address - Country:US
Practice Address - Phone:909-596-4879
Practice Address - Fax:909-596-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A525191Medicaid
CAA52519Medicare ID - Type Unspecified
CA00A525191Medicaid